Medication Reconciliation Form printable pdf download

EDICATION

ASSPORT

TANDARDS

The list of Medication Passport standards has been developed through the collaborative effort of Medication Management Workgroup of the Health

Care Improvement Foundation’s PAVE Project. It has been designed incorporating all of the critical components of an effective, clear and concise

medication reconciliation and transfer form. The form incorporates key elements, not only for the providers, but for patients, as well. The Workgroup

recognized that each hospital may already have a similar form in use and, therefore, prepared the Medication Passport as a way to identify the

critical components that should be included in all medication reconciliation and transfer forms.

Standards:

Process:

 Include the Medication Passport or like as part of the discharge instructions and given to the patient at discharge.

 Provide copy to primary care physician within 48 hours of discharge along with discharge note/summary.

Form Design:

 Spell out all words on the form. Do not use any abbreviations.

 Use language that both the patient will understand (e.g., plain language) and that will convey the essential information to the provider.

 Provide ample space for listing the active medications at discharge.

 Provide area for listing pre-hospital medications that have been discontinued.

Data Elements:

 Include the reason for admission in patient-friendly language.

 Include the date of discharge.

 List both generic and brand names listed for each medication.

 Include field for special instructions, to include important dates as they relate to drug therapies.

 Include field for why the medication has been prescribed.

 Indicate when next dose of each medication is due.

 Indicate each page number and the total number of pages completed.

 Provide contact information for the discharging physician.

 Provide contact information for the patient’s primary care provider.

 Provide contact information for the patient’s community pharmacy.

Optional Fields to Consider:

 Stop date/duration of therapy.

 Flu/Pne vaccine status.

 Add field to indicate whether the primary care provider has been contacted.

Health Care Improvement Foundation, June 2011

Medication Reconciliation Form