Provider Resources

Medication Reconciliation Order Form

Bayshore Community Hospital, New Jersey

This two-page form can be used to record all current home medications before the patient receives any medicines related to a test or procedure at an outpatient facility. It also contains a pharmacy listing for additional patient convenience.

Admission Orders for Medications PRIOR to Admission

Emory Healthcare, Georgia, 02/2006

This one-page form includes sections to record patient’s vaccination status, allergies and medicines prior to admission, and a table for ordering medicines at admission.

Preadmission Medication List Verification and Order Form

UMass Memorial, Massachusetts

This two-page medication verification form includes a table to record patient medicines, provides instructions for effective use, and lists prohibited abbreviations.

UMass Memorial Medical Center and Mercy Medical Center

This two-page document describes medication reconciliation at admission with the help of flowcharts at two healthcare facilities.

Medication Reconciliation Made Easy

American Society of Health-System Pharmacists

This flyer lists ways in which a doctor/nurse can obtain information about patient’s home medications when the patient is unsure.

UWHC Medication Reconciliation Form

University of Wisconsin Hospital and Clinics (UWHC), Wisconsin, 02/2008

This four-page form can be used to audit the medication reconciliation process at admission, during transfer, at discharge and when care is delivered at a non-inpatient facility.

Medication Reconciliation Education Packet

University of Wisconsin Hospital and Clinics (UWHC), Wisconsin

This nine-page document educates non-pharmacy healthcare professionals about obtaining accurate drug lists from patients. It also includes a table of commonly- encountered confusing abbreviations.

University of Kentucky Hospital Med Rec Policy

University of Kentucky Hospital, Chandler Medical Center, Kentucky, 02/2006

This hospital policy provides a list of items that are classified as medicines (not exhaustive), and describes the medicine reconciliation process at a hospital with clear instructions.

Medication Reconciliation Form

Holyoke Hospital, Massachusetts

This one-page form can be used to reconcile medicines between physician and the specialist.

Reconciling Medications Team Planning – New Patient Safety Initiative

Massachusetts Coalition for the Prevention of Medical Errors – Reconciling Medications Collaborative

This one-page form helps to identify team members for a Medication Reconciliation team.

Worksheet for Testing Change

Massachusetts Coalition for the Prevention of Medical Errors – Reconciling Medications Collaborative

This two-page worksheet is an example of how to use the Aim, Plan, Do, Study, Act (PDSA) cycle to test and measure change in medication reconciliation success rates.

Return on Investment (ROI) Analysis

American Society of Health-System Pharmacists, 08/2007

This Excel worksheet is a tool to calculate hospital Return on Investment (ROI) for hiring additional pharmacist support for MR upon admission. The user can get quick ROI estimates by entering hospital-specific data in the fields provided.

Thomson Clinical Xpert Medication Reconciliation

Thomson Healthcare, 05/2007

This white paper describes medication issues and trends, joint commission mandates, medication reconciliation challenges and Thompson Healthcare’s product clinical Xpert medication reconciliation electronic system.

Discharge Medication Prescription Form

Emory Healthcare, Georgia, 03/2007

This two-page form is used for prescribing medicines at discharge. It also includes instructions for doctors, nurses, patients and pharmacists to effectively use the form.