Medication Reconciliation Audit Tool Template - Discharge Page 2
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1
2Medication Discrepancy Tool (MDT)
Facility Name: _______________________________________Date of Discharge:____________________
Patient Identifier (facility use only): _________________________________________________________
Data Collector’s name: ________________________________Email/Phone:________________________
If used in conjunction with the Medication Reconciliation Audit Form, circle one of the following to indicate the corresponding
patient record: Pt.1 Pt.2 Pt.3 Pt.4 Pt.5
Instructions: Document and explain any discrepancies in the patient’s medication orders that could have resulted in a medication
error. Multiple causes and contributing factors can be selected if needed using the list below.
Medication
Cause & Contributing Factors
Resolution
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Causes and Contributing Factors:
a. Ordered medication conflicts with patient’s listed
e.
Drug name discrepant/incorrect
allergies
f.
Medications omitted
b. Discharge instructions and/or summary incomplete,
g. Patient level factors (did not fill/obtain medication,
inaccurate, does not match MAR, PRI, etc.
did not take medication at all or as prescribed, did
c.
Duplication (multiple drugs ordered with the same
not understand use of the medication, need for
action without any rationale)
patient assistance not recognized)
d. Dose/Frequency discrepant
h. Other
Name of the facility where patient was discharged to: _______________________________________________
Was there a delay in starting the appropriate medications for the patient? Y N If yes, how long? __________
SM
The Medication Discrepancy Tool was created by Care Transitions Intervention
– Eric Coleman, MD, MPH, and adapted by the Atlantic Quality Innovation
Network/IPRO, the Medicare Quality Innovation Network Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily
reflect CMS policy.
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