NH Materials Package to Go with New Orientation/Training Presentation

MEDICATION RECONCILIATION Patient Name:

ASSESSMENT of PATIENT RISK (APR) TOOL

Assessment of Patient Risk (circle all applicable factors)
Age / 0 – 64 years / 0 / Examples of medications for each medication category:
Antiseizure e.g. carbamazepine, phenytoin, valproic acid & divalproex sodium.
Anticoagulants e.g. warfarin, low molecular weight heparin (e.g. enoxaparin, nadroparin), heparin. NOT ASA.

Cardiovascular Medications

e.g. blood pressure meds, cholesterol meds, digoxin, amiodarone, daily ASA, clopidogrel, diuretics.
Do not count anticoagulants as a cardiovascular medication.

Diabetic Medications

e.g. chlorpropamide, gliclazide, glyburide, metformin, rosiglitazone
65 – 80 years / 1
> 80 years / 2
Number of Medications Prior to Admission / 0-1 / 0
2-4 / 2
5-7 / 3
8 or more / 6
High Risk Medications
Prior to Admission / Antiseizure / 3
Anticoagulant / 3
More than two cardiovascular medications / 5
Diabetic medications (oral +/- insulin) / 2
Is the reason for admission clearly drug-related (e.g. drug toxicity, non-compliance, polypharmacy)? / Yes
No

Total Score

Referral to Clinical Pharmacy Team Recommended/Required?  Yes  No  Unsure
Reason for referral:
Form completed by:
Date: / If total score is  10, if referral to a pharmacist is recommended or if the reason for admission is drug-related - place form in troubleshooting file

For Demo Purposes

Pharmanet medication information for past 15 months

9029 820 762 HARRISON, CAROL A – 1927 Feb 01 – F

Reported Clinical Conditions – 1 found:

HYPERCHOLESTEREMIA

1999 Mar 01 Patient

Reported Adverse Reactions – 2 found:

510645SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET

2000 Jul 18 P1/02301RASH

2043246PENICILLIN G POTASSIUM WYETH-AYERST CA 10MU VIAL

1996 Jan 0191/15399ANAPHYLAXIS

Reported Medication History – 15 of 15 printed:

510645SULFAMETHOXAZOLE/TRIMETHOPRIM NOVOPHARM LTD 800-160MG TABLET

14 @ 2/dayTAKE ONE TABLET TWICE DAILY

Reversed: 2006 Oct 10 91/07692 (HARDY) Prescription cancelled by physician

2169126P-EPHED HCL/CODEINE/TRIPROL RATIOPHARM 30-10-2/5 LIQUID

250 @ 8.333/dayTAKE 5 TO 10 ML EVERY 6 HOURS AS NEEDED

Filled: 2006 Aug 0891/03361 (LAVOY)

28053 SULFACETAMIDE SODIUM SCHERING CANADA 10% DROPS

15 @ 2.143/day2 DROPS IN EACH EYE EVERY 3 HOURS FOR 7 DAYS

Filled: 2006 Aug 0891/03361 (LAVOY)

2213672FLUTICASONE PROPIONATE GLAXO SMITH KLINE 50MCG SPRAY

120 @ 4/dayUSE TWO SPRAYS IN EACH NOSTRIL DAILY

Filled: 2006 Jul 3191/07692 (HARDY)

607789HYDROCORTISONE ACETATE/ZN SULF RATIOPHARM 0.5%-0.5% OINT. (GM)

30 @ 1/dayAPPLY RECTALLY TWICE DAILY

Filled: 2006 Jul 3191/07692 (HARDY)

Page 1 of 2

2043408ESTROGENS, CONJUGATED WYETH CANADA 0.625MG TABLET

90 @ 1/day TAKE ONE TABLET ONCE DAILY

Filled: 2006 Jul 28 91/02295 (MACKAY)

2014165 THEOPHYLLINE ANHYDROUS PURDUE PHARMA 400MG TAB SR 24H

90 @ 1/day TAKE ONE TABLET ONCE DAILY

Filled: 2006 Jul 2891/02295 (MACKAY)

2221926CYANOCOBALAMIN SABEX 1000MCG/1ML INJECTION

3 @ 0.033/day INJECT 1ML INTRAMUSCULARLY ONCE MONTHLY

Filled: 2006 Jul 28 91/02295 (MACKAY)

2007959ACETYLSALICYLIC ACID PHARMASCIENCE 81MG TABLET DR

90 @ 1/dayTAKE ONE TABLET ONCE DAILY

Filled: 2006 Jul 18 91/02295 (MACKAY)

2091291 AZITHROMYCIN PFIZER CANADA 250MG TABLET

6 @ 1/dayTAKE TWO TABS TO START THEN 1 TAB DAILY FOR 4 DAYS

Filled: 2006 Jun 16 91/03654 (KENNEDY)

2162423NAPROXEN HOFFMAN-LAROCHE 500MG TABLET DR

20 @ 2/dayTAKE ONE TABLET TWICE DAILY

Filled: 2006 Jun 1691/03654 (KENNEDY)

460990THEOPHYLLINE ANHYDROUS ASTRAZENECA 200MG TAB SR 12H

180 @ 2/dayTAKE ONE TABLET EVERY 12 HOURS

Filled: 2006 Apr 2891/02295 (MACKAY)

21016QUININE SULFATE NOVOPHARM LTD 300MG CAPSULE

60 @ 1/dayTAKE ONE CAPSULE AT BEDTIME AS NEEDED FOR LEG CRAMPS

Filled: 2006 Apr 2891/02295 (MACKAY)

2043408ESTROGENS, CONJUGATED WYETH CANADA 0.625MG TABLET

90 @ 1/day TAKE ONE TABLET ONCE DAILY

Filled: 2006 Apr 2891/02295 (MACKAY)

2163926CODEINE/ACETAMINOPHEN/CAFFEINE JANSSEN-ORTHO 30-300-15 TABLET

100 @ 4/dayTAKE ONE TABLET EVERY 4 TO 6 HOURS AS NEEDED FOR PAIN

Filled: 2006 Apr 03 91/09951 (MCCARTHY)

Page 2 of 2

SAFER HEALTHCARE NOW PHARMACY

1234 Summerset Blvd Prince George, BC V2M 3A0
Ph: 250 987-1234 Fx: 250 987-6543
Rx 123456 Jul 28 2006
CAROL HARRISON Dr. L. MacKay

TAKE ONE TABLET ONCE DAILY

90 Estrogens, Conjugated 0.625mg (Wyeth) 2043408
**TRAINING PURPOSES ONLY** /

SAFER HEALTHCARE NOW PHARMACY

1234 Summerset Blvd Prince George, BC V2M 3A0
Ph: 250 987-1234 Fx: 250 987-6543
Rx 123457 Jul 28 2006
CAROL HARRISON Dr. L. MacKay

TAKE ONE TABLET ONCE DAILY

90 Theophylline Anhydrous 400mg SR (Purdue) 2014165
**TRAINING PURPOSES ONLY** /

SAFER HEALTHCARE NOW PHARMACY

1234 Summerset Blvd Prince George, BC V2M 3A0
Ph: 250 987-1234 Fx: 250 987-6543
Rx 123458 Jul 28 2006
CAROL HARRISON Dr. L. MacKay

TAKE ONE TABLET ONCE DAILY

90 A.S.A. EC 81mg (Pharmascience) 2007959
**TRAINING PURPOSES ONLY** /

CAROL HARRISON’S

PRESCRIPTION VIAL LABELS

MEDICATION HISTORY

CAROL HARRISON

______

For Demo Purposes

Pharmanet medication information for past 15 months

9783 671 993 SMTIH, EVELYN M – 1941 Oct 16 – F

Reported Clinical Conditions – 0 found:

Reported Adverse Reactions – 0 found:

Reported Medication History – 18 of 18 printed:

02202441OXYCODONE PURDUE PHARMA 10MG TABLET CR

56 @ 2/dayTAKE ONE TABLET EVERY 12 HOURS

Filled: 2006 Oct 16 91/05568 (BROWN)

2237280VENLAFAXINE WYETH CANADA 75MG CAPSULE XR

60 @ 1/dayTAKE ONE CAPSULE ONCE DAILY

Filled: 2006 Sep 11 91/05568 (BROWN)

2237280VENLAFAXINE WYETH CANADA 75MG CAPSULE XR

30 @ 1/dayTAKE ONE CAPSULE ONCE DAILY

Filled: 2006 Aug 03 91/05568 (BROWN)

2221845RAMIPRIL AVENTIS PHARMA 5MG CAPSULE

180 @ 2/dayTAKE TWO CAPSULES ONCE DAILY

Filled:2006 Aug 0391/05568 (BROWN)

337749FUROSEMIDE NOVOPHARM 40MG TABLET

45 @ 0.5/dayTAKE ONE HALF OF A TABLET ONCE DAILY IN THE MORNING

Filled: 2006 Aug 0391/05568 (BROWN)

2242323 DIGOXIN VIRCO 0.25MG TABLET

90 @ 1/dayTAKE ONE TABLET ONCE DAILY

Filled: 2006 Aug 03 91/05568 (BROWN)

1913662GLYBURIDE APOTEX 5MG TABLET

90 @ 1/dayTAKE ONE TABLET ONCE DAILY

Filled: 2006 Aug 03 91/05568 (BROWN)

Page 1 of 2

2237244FLUTICASONE GLAXOSMITHKLINE 50MCG DISKUS

60 @ 2/dayINHALE ONE PUFF TWICE DAILY

Filled: 2006 Aug 0391/05568 (BROWN)

2221926CYANOCOBALAMIN SABEX 1000MCG/1ML INJECTION

3 @ 0.03/day INJECT 1ML INTRAMUSCULARLY ONCE MONTHLY

Filled: 2006 Aug 03 91/05568 (BROWN)

00451193 TIMOLOL MERCK FROSST 0.25% EYE DROPS

15 @ 0.5/day INSTIL ONE DROP INTO EACH EYE TWICE DAILY

Filled: 2006 Aug 0391/05568 (BROWN)

2221845RAMIPRIL AVENTIS PHARMA 5MG CAPSULE

180 @ 2/dayTAKE TWO CAPSULES ONCE DAILY

Filled:2006 Apr 2291/05568 (BROWN)

337749FUROSEMIDE NOVOPHARM 40MG TABLET

45 @ 0.5/dayTAKE ONE HALF OF A TABLET ONCE DAILY IN THE MORNING

Filled: 2006 Apr 2291/05568 (BROWN)

2242323 DIGOXIN VIRCO 0.25MG TABLET

90 @ 1/dayTAKE ONE TABLET ONCE DAILY

Filled: 2006 Apr 2291/05568 (BROWN)

1913662GLYBURIDE APOTEX 5MG TABLET

90 @ 1/dayTAKE ONE TABLET ONCE DAILY

Filled: 2006 Apr 2291/05568 (BROWN)

2237244FLUTICASONE GLAXOSMITHKLINE 50MCG DISKUS

60 @ 2/dayINHALE ONE PUFF TWICE DAILY

Filled: 2006 Apr 2291/05568 (BROWN)

2221926CYANOCOBALAMIN SABEX 1000MCG/1ML INJECTION

3 @ 0.03/day INJECT 1ML INTRAMUSCULARLY ONCE MONTHLY

Filled: 2006 Apr 2291/05568 (BROWN)

00451193 TIMOLOL MERCK FROSST 0.25% EYE DROPS

15 @ 0.5/day INSTIL ONE DROP INTO EACH EYE TWICE DAILY

Filled: 2006 Apr 2291/05568 (BROWN)

Page 2 of 2

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS

Allergies/Intolerances
(specify reactions)
Weight
______ kg  lbs
 Estimated  Actual / Height
______ m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time
 Caregiver ______Ph:…………..…
 Pharmacy ______Ph:……….…..…
History Documented by
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages ____ of ____

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Ramipril capsule / 10mg / PO / Daily
CHANGE ORDER
COMMENTS
Blood pressure / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Furosemide tablet / 20mg / PO / QAM
CHANGE ORDER
COMMENTS
Water pill / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Digoxin tablet / 0.25mg / PO / Daily
CHANGE ORDER
COMMENTS
Heart / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Glyburide tablet / 5mg / PO / Daily
CHANGE ORDER
COMMENTS
Diabetes / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Venlafaxine XR capsule / 75mg / PO / Daily
CHANGE ORDER
COMMENTS
Depression / Last Dose Date/Time
2200hr 25Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Oxycodone CR tablet / 10mg / PO / q12h
CHANGE ORDER
COMMENTS
Osteoarthritis Prescribed 10 days ago / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages _1___ of __2_

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Fluticasone Diskhaler / 50mcg (1 puff) / INH / BID
CHANGE ORDER
COMMENTS
Breathing Non-compliance: Using 1 inhaler q3mths / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Vitamin B12 Injection / 1000mcg / IM / qmth
CHANGE ORDER
COMMENTS
Anemia Next dose due: 20Nov06 / Last Dose Date/Time
0800hr 20Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Mulitvitamin tablet / 1 tab / PO / Daily
CHANGE ORDER
COMMENTS
Poor diet / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Timolol 0.25% eye drops / 1 drop each eye / opht / BID
CHANGE ORDER
COMMENTS
Glaucoma Non-compliance: Using 15ml q3mths / Last Dose Date/Time
0800hr 25Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages _2___ of __2_

Northern Health Authority

Northeast Health Services

Fort St. John Hospital & Health CentreFOR TRAINING PURPOSES

PHYSICIAN’S ORDERSEVELYN SMITH

A U T O M A T I C S T O P O R D E R S

Medication orders not stating the number of days or doses

will be subject to the following automatic stops.

Demerol (Parental) 3 days

Anti-infectives (oral) 7 days

Anti-infectives (parenteral) 3 days

ALC Drugs90 days

Ketoroloc 5 days

All Other Drugs30 days

DRUG ALLERGIES NKA / PATIENT WT.90 KG.
LBS.

DATE OF ORDER

√

PHYSICIAN’S ORDERS

PROGRESS NOTES

Today’s

Altace 5mg po daily

Dizziness  Altace from 10mg

Date / Furosemide 40mg po qam
Digoxin 0.125mg po daily
Glyburide 5mg po daily
Ranitidine 150mg po hs
Insulin 30/70 10 U sc bid
Effexor 75mg po bid
Oxycodone 10mg po q12h
Flovent MDI 50mcg i bid
Oxazepam 15mg po hs
Docusate 100mg po hs prn
Sennosides 12mg ii hs prn

Glycerin supp i pr prn

Vitamin B12 1,000mcg IM qmth
Multivitamin i po daily
Dr. B. Brown

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Ramipril capsule / 10mg / PO / Daily / 1
PRE-ADMISSION MEDICATION
Ramipril capsule / 5mg / PO / Daily
COMMENTS
Blood pressure / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
7
PRE-ADMISSION MEDICATION
Furosemide tablet / 20mg / PO / QAM / ?
CHANGE ORDER
Furosmide tablet / 40mg / PO / QAM
COMMENTS
Water pill / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Digoxin tablet / 0.25mg / PO / Daily / ?
CHANGE ORDER
Digoxin tablet / 0.125mg / PO / Daily
COMMENTS
Heart / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Glyburide tablet / 5mg / PO / Daily / 0
CHANGE ORDER
COMMENTS
Diabetes / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Venlafaxine XR capsule / 75mg / PO / Daily / ?
CHANGE ORDER
Venlafaxine tablet / 75mg / PO / BID
COMMENTS
Depression / Last Dose Date/Time
2200hr 25Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Oxycodone CR tablet / 10mg / PO / q12h / ?
CHANGE ORDER
Oxycodone IR tablet / 10mg / PO / q12h
COMMENTS
Osteoarthritis Prescribed 10 days ago / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages _1___ of __2_

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Fluticasone Diskhaler / 50mcg (1 puff) / INH / BID / ?
CHANGE ORDER
Fluticasone MDI / 50mcg (1 puff) / INH / BID
COMMENTS
Breathing Non-compliance: Using 1 inhaler q3mths / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
Vitamin B12 Injection / 1000mcg / IM / qmth / 0
CHANGE ORDER
COMMENTS
Anemia Next dose due: 20Nov06 / Last Dose Date/Time
0800hr 20Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Mulitvitamin tablet / 1 tab / PO / Daily / 0
CHANGE ORDER
COMMENTS
Poor diet / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Timolol 0.25% eye drops / 1 drop each eye / opht / BID / ?
CHANGE ORDER
Nil
COMMENTS
Glaucoma Non-compliance: Using 15ml q3mths / Last Dose Date/Time
0800hr 25Oct / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages _2___ of __2_

MEDICATION RECONCILIATIONADDRESSOGRAPH

DISCREPANCY CLARIFICATION & RESOLUTION

Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
PRE-ADMISSION MEDICATION
ORDER AT ADMISSION
COMMENTS /  Continue admission
order /  Revert to pre-admission
order
Source of Information / Discrepancy Types
Undocumented Intentional
 Resolution: Continue
admission order
Unintentional
 Resolution: Revert to pre-
admission order
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time
 Caregiver ______Ph:…………..…
 Pharmacy ______Ph:……….…..…
History Documented by
Authorizing Physician Date/Time /  Faxed to Pharmacy
Pages ____ of ____

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Ramipril capsule / 10mg / PO / Daily / 1
PRE-ADMISSION MEDICATION
Ramipril capsule / 5mg / PO / Daily
COMMENTS
Blood pressure / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
7
PRE-ADMISSION MEDICATION
Furosemide tablet / 20mg / PO / QAM / 2
CHANGE ORDER
Furosmide tablet / 40mg / PO / QAM
COMMENTS
Water pill / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
3
PRE-ADMISSION MEDICATION
Digoxin tablet / 0.25mg / PO / Daily / 2
CHANGE ORDER
Digoxin tablet / 0.125mg / PO / Daily
COMMENTS
Heart / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE / CHANGE
4
PRE-ADMISSION MEDICATION
Glyburide tablet / 5mg / PO / Daily / 0
CHANGE ORDER
COMMENTS
Diabetes / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Venlafaxine XR capsule / 75mg / PO / Daily / 3
CHANGE ORDER
Venlafaxine tablet / 75mg / PO / BID
COMMENTS
Depression Ordered immediate release in error / Last Dose Date/Time
2200hr 25Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Oxycodone CR tablet / 10mg / PO / q12h / 3
CHANGE ORDER
Oxycodone IR tablet / 10mg / PO / q12h
COMMENTS Osteoarthritis Prescribed 10 days ago
Ordered immediate release in error / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Dr.B.Brown/Lois Pharma Date/Time Today’s Date /  Faxed to Pharmacy
Pages _1___ of __2_

ADDRESSOGRAPH

MEDICATION HISTORY & ORDERS Evelyn Smith

Allergies/Intolerances
(specify reactions)
Weight
__90__  kg  lbs
 Estimated  Actual / Height
_5’ 9”__  m / cm  ft / in
 Estimated  Actual
Generic Name / Dose / Route / Frequency / Floor Use
PRE-ADMISSION MEDICATION
Fluticasone Diskhaler / 50mcg (1 puff) / INH / BID / 3
CHANGE ORDER
Fluticasone MDI / 50mcg (1 puff) / INH / BID
COMMENTS Breathing Non-compliance: Using 1 inhaler q3mths
MDI ordered instead of Diskhaler / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Vitamin B12 Injection / 1000mcg / IM / qmth / 0
CHANGE ORDER
COMMENTS
Anemia Next dose due: 20Nov06 / Last Dose Date/Time
0800hr 20Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Mulitvitamin tablet / 1 tab / PO / Daily / 0
CHANGE ORDER
COMMENTS
Poor diet / Last Dose Date/Time
0800hr 26Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
Timolol 0.25% eye drops / 1 drop each eye / opht / BID / 3
CHANGE ORDER
Nil
COMMENTS Glaucoma Non-compliance: Using 15ml q3mths / Last Dose Date/Time
0800hr 25Oct / D/C / CONTINUE
1 / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
PRE-ADMISSION MEDICATION
CHANGE ORDER
COMMENTS / Last Dose Date/Time / D/C / CONTINUE / CHANGE
Source of Information / Verification Codes
1 Indication 5Wrong Drug
2 No Indication 6 Non-Compliance
3 Dose Too Low 7 Adverse Event
4 Dose Too High 8 Drug Interaction
 Interviewed Patient  Poor Historian /  Pharmanet
 Prescription containers
 Medication List
 MAR
 Other______
Date/Time Today’s Date
 Caregiver John Smith Ph:992-1234
 Pharmacy Pharmasave Ph: 994-4444
History Documented by Alana Froese
Authorizing Physician Dr.B.Brown/Lois Pharma Date/Time Today’s Date /  Faxed to Pharmacy
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