Endoscopic Imaging Center Medication Reconciliation Form printable pdf download

Endoscopic Imaging Center Medication Reconciliation Form

Endoscopic Imaging Center

Medication Reconciliation Form

ALLERGIES:

Medication History – Include Over the Counter Medications

Last Dose

Taken

Medication Name

Dose

Route

Frequency

Comments

Medication/Allergy History provided by: ____________________________Date:_________Time:_________

Resume all pre-procedure medications as ordered previously by prescribing physician. Exceptions/explanations

listed below

________________________________________________________________________________________________________________________

________________________________________________________

Additional Home Medications for Patient discharge

Medication Name

Dose/Route/Frequency/Comments

Rx Given?

Physician’s signature: _______________________________________Date__________Time________

Patient/Responsible Party signature_____________________________Date__________Time________

Discharge Nurse signature ____________________________________Date__________Time________

Endoscopic Imaging Center Medication Reconciliation Form