Simi Surgery Center - Medication Reconciliation Form
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1SIMI SURGERY CENTER MEDICATION RECONCILIATION FORM
Patient Allergy Validation Sticker
NOT CURRENTLY TAKING HOME MEDICATIONS
To Be Completed for
Route
Indication
Discharge
Names of Medications
Dose
Frequency
(how)
(Why
Last
(How
(mg)
(oral,
taking
Dose
Often)
inj,
med?)
taken
Resume
Change
Add to
Disconti
as pre-
To:
list
nue
patch)
on
op !
!
!
PHYSICIAN TO COMPLETE THIS SECTION: POST-OP MEDICATION ORDERS:
PHYSICIAN SIGNATURE__________________________________ DATE _______________
Signature of RN obtaining original list ___________________________________________
Signature of discharge RN ____________________________________________________
Note to Patient: Please take this medication list to your next doctor’s appointment. It is recommended that you bring
a list of your current medications to each medical appointment.
Signature of Patient___________________________________________ Date___________________
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