Medication Reconciliation - Baylor Health Care System
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1MEDICATION RECONCILIATION
: ________________________________________
Allergies
□ Latex □ Tape □ Iodine □ No Known Drug Allergies
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Information Source:
Patient
Caregiver/Family
Other: _______
Unable to obtain due to
Patient condition
Patient’s knowledge of meds
(Include all herbals, prescription, over the counter, eye drops, inhalers, vitamins and supplements)
Given on Discharge
P=Prescription
DATE
Drug Name and Dosage
Route
How often taken
S=Samples
other than
each day
by mouth
The listed medications are correct. I, the undersigned, have read and understand these instructions. I understand if prescriptions are to be filled, I
will do this at the pharmacy of my choice. □ I have been provided with a copy of this form to give to my next care provider.
Signature of Patient or Authorized Representative: _____________________________________________________Date/Time:____________
Signature of Clinician Reviewing Discharge Instructions:________________________________________________ Date/Time:____________
Subsequent Patient Visits
I verify that I or my informant have reviewed the Out Patient Data Base dated ________________(with a date within 30 days). All of the
information is complete and correct and I have made all necessary revisions.
□ I have been provided with a copy of this form to give to my next provider of care
Signature of Patient or Authorized Representative: _____________________________________________________Date/Time:____________
Signature of Clinician Reviewing Discharge Instructions:________________________________________________ Date/Time:____________
□ I have been provided with a copy of this form to give to my next provider of care
Signature of Patient or Authorized Representative: _____________________________________________________Date/Time:____________
Signature of Clinician Reviewing Discharge Instructions:________________________________________________ Date/Time:____________
□ I have been provided with a copy of this form to give to my next provider of care
Signature of Patient or Authorized Representative: _____________________________________________________Date/Time:____________
Signature of Clinician Reviewing Discharge Instructions:________________________________________________ Date/Time:____________
BAYLOR UNIVERSITY MEDICAL CENTER
MARTHA FOSTER LUNG CARE CENTER
OUTPATIENT DATABASE INFORMATION
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