Medication Reconciliation Tool Form - South Country Health Alliance Page 2
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1
2Medication Reconciliation Tool
Member Name: __________________________________
Member PMI #: ___________________________
Medication Discrepancy Event Description: (if additional space is needed use another form)
Event #
Medication
Dose
Frequency
Route
1
2
3
4
5
6
Cause and Contributing Factors: Place the Medication Discrepancy Event number to the left of each factor that applies:
Patient Level
System (Agency/Clinic/Hospital) Level
Adverse Drug Reaction
Prescribed with known allergies
Intolerance
Conflicting information from different sources
Did not fill prescription
Confusion between brand & generic names
Did not need prescription
Discharge information incomplete/inaccurate/illegible
Money/Financial Barrier
Duplication of drug
Incorrect dosage
Incorrect quantity
No care giver/need for assistance not recognized
Cognitive impairment not recognized
Questions:
1. Did you call the primary care provider to clarify and clear up discrepancies?
Yes
No
2. 2. Did the member receive a reconciled medication list?
Yes
No
3. Did you send a copy of this tool to the primary care provider?
Yes
No
4. 4. Did you send a copy of this tool to the member’s County Care Coordinator?
Yes
No
Resolution: Check all that apply
Advised member to stop taking/start taking/change administration of medication
Discussed harm that may result from non-adherence
Discussed potential benefits for adherence (preventing future unplanned transitions)
Addressed performance/knowledge deficit
Provided additional community resources to facilitate adherence
Member Refused Visit – Reason: ___________________________________________________________
Other: ________________________________________________________________________________
**Registered Nurse/Public Health Nurse: I have reviewed the current medications, by interview of member and viewing of pill
container, and reconciled with hospital discharge medication list
Nurse’s Signature _________________________________ County/Home Health Care Agency ___________________________
Date of Medication Reconciliation _____________________________________
Page 2 – 04/01/2014
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