Medication Reconciliation Form Page 2
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2
3PATIENT ID LABEL
FACILITY NAME
MEDICATION PASSPORT
Main Reason for Admission:
Today’s Date:
Allergies:
Patient reports no known medication allergies
No documented medication allergies
Medication to Avoid
Reaction if taken
Medication to Avoid
Reaction if taken
COMMENTS/
Active Medications For
MEDICATION
MEDICATION
HOW TO
TAKE NEXT
REASON
DOSE
SPECIAL
After Hospital Discharge
BRAND NAME
GENERIC NAME
TAKE
DOSE AT
FOR USE
INSTRUCTIONS
New
Dose change
Continuation
New
Dose change
Continuation
New
Dose change
Continuation
New
Dose change
Continuation
New
Dose change
Continuation
(Add more lines as needed)
Medications that should no longer be taken:
MEDICATION
COMMENTS
Discharging Physician’s Name (please print):
Phone #: ___________________
Primary Care Provider’s Name (please print):
Phone #: ___________________
Pharmacy: _ ___________________________________________
Phone #:
Page
of
Health Care Improvement Foundation, June 2011
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