Form 70811 - Medication Reconciliation Order Form - 2006

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MEDICATION RECONCILIATION ORDER FORM
List all patient medications prior to assessment. Include OTCs & alternative meds (herbals). (Alternative meds will not be continued on admission).
Before an outpatient receives any medication as part of their test or procedure, list all of their current home medications looking for allergies,
interactions, duplications, or other concerns. A complete reconciliation is required only if the patient is to be admitted to the hospital.
Allergies:
DO NOT USE ABBREVIATIONS: .#, #.0, IU, MS, MgSO4, MSO4, QD, QOD, U
Information Source:
_____ Patient
_____ Family
_____ Primary Care Physician
_____ Patient’s Pharmacy(s) _______________________________________________________________ (See Back)
_____ MAR from _______________________________
_____ Other, specify _______________________________
□ Check here if patient is not currently on any medication.
Last Dose
Physician Decision:
Continue? Circle one
Medication Name
Dose
Route
Frequency
Date
Time
Y
N
1
Y
N
2
Y
N
3
Y
N
4
Y
N
5
Y
N
6
Y
N
7
Y
N
8
Y
N
9
Y
N
10
Y
N
11
Y
N
12
Y
N
13
Y
N
14
Y
N
15
On the lines below, enter orders for new medications that the patient isn’t currently taking or changes to their current regimen.
Completed by _________________________ Nurse Signature _______________________ Date/Time ___________ ___
(print name)
I have reviewed this list of patient medications and to the best of my knowledge, the additional medications I have
ordered will not result in any adverse reaction(s).
Completed by _________________________ MD Signature _________________________ Date/Time ___________ ___
(print name)
Faxed/Given to _____________________________ By _____________________________ Date/Time __________ ____
(sign & print name)
Sheet _____ of _____
70811 (REV 6/06)

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