Medication Reconciliation Record Form
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1Please write down your prescription medications on this form. Make sure you provide us with the dosage
of each prescription medication as well as how often you are to take the medication and the last time you
took it. Lastly, please bring this form with you on the day of your procedure. The physician will need to
review all of your medications post procedure at the time of your discharge from our facility. At this time
the physician will document whether or not you may continue, or discontinue your medications after
your procedure.
Medication Reconciliation Record
Medication
Dose
How Often
Last Time Taken
Post Procedure Instructions
(ONE Medication Per Box)
(amt)
(Frequency)
(Physician Use Only)
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Continue
Discontinue
__________________
Nurse Use
Only: Do you take any aspirin or
List Medications:
No Restrictions
Refrain from Using
aspirin like products? ( ie aspirin, advil, aleve,
Please Resume Use
for _____ Days
ibuprofen)
No Restrictions May
Refrain from Using
Please refrain from taking any NSAID products
such as:
Use as Needed
for _____ Days
Aspirin, Aleve, Naprosyn, Advil / Ibuprofin,
Excedrin and Mobic
PreOP RN Signature_________________
MD Signature_________________________
Date_________________________
Date_________________________________
Revised 10/27/2015 mca
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