Medication Reconciliation Tool Form - South Country Health Alliance

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Medication Reconciliation Tool
County of Residence
Member Name
Member PMI #
Hospital
Yes
No
Discharge Date
Member Refused Visit?
DIRECTIONS: Please document the current medications prescribed and verify if a discrepancy is found when comparing the inpatient discharge medication list and the
current medication list.*
Medication
Dose
Route
Frequency
How
Taking as
Not Taking
Discrepancy
*(if additional space is needed, please use another page)
Many?
Prescribed (Y/N)
(Yes/No)
Found (Yes/No)**
SAMPLE: Celebrex
25mg
PO
BID (AM/PM)
2
No
No
Yes
** If a discrepancy is found, please document the event, contributing factors, and resolution on the next page. Sign document.
Page 1 – 04/01/2014

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