Medication Reconciliation Form
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1Medication Reconciliation Form
Source of info:
Patient
Med Bottles
Family
List
Other
Allergies and Reactions:_____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List all prescription, over-the-
Dosage
Frequency
Dc'd
Last Dose
Comments
Prior to
counter, vitamins and
Surgery
herbal/natural
medications taken routinely
See Attached List
Post-op Medications
Patient/Parent/Guardian Signature:_________________________________Date:________Time:________
Signature of Nurse obtaining original list:____________________________Date:________Time:________
Unless otherwise indicated, please resume medications which have been prescribed to you when
you return home.
Signature of Nurse discharging patient:______________________________Date:________Time:________
revised 2/11
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