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Pharmacy Note: Medication Reconciliation

The patient’s medical records reveal the following information about home medications:

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Medication Name

[Brand Name]

Strength Dose Route Frequency
         
         
         
         
         
         
         

The clinic note from [month day, 20XX], and hospital admission note from [month day, 20XX], were reviewed. The patient’s [family member] was contacted by phone on [month day, 20XX], to clarify discrepancies between the clinic and hospital admission home medication lists.

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Medication

Name

Medication Discrepancy?

Yes/No

Home Medication List Recommendation

If there was a home medication discrepancy, include here how to update the home medication list.

Hospital Admission Medication List Recommendation

Provide whether to hold or continue each home medication upon admission to hospital. If choosing to hold upon admission, provide brief reason for holding.

   

Medication Name:

Strength:

Dose:

Route:

Frequency:

 
   

Medication Name:

Strength:

Dose:

Route:

Frequency:

 
   

Medication Name:

Strength:

Dose:

Route:

Frequency:

 
   

Medication Name:

Strength:

Dose:

Route:

Frequency:

 
   

Medication Name:

Strength:

Dose:

Route:

Frequency:

 

Please contact the pharmacy department at extension 1199 if you have any questions or concerns.

Signed electronically by [insert name and credentials] on month day, 20XX, at [insert time].

*Template was created by and used with permission from Southern Illinois University Edwardsville School of Pharmacy.

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