Western Regional Integrated Health Authority
*For LTC O’Connell/DVA Unit Use Only*
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
**Keep this form with the Physician Orders** / Site:
 O’Connell LTC
 O’Connell Rehab
Patient Label/Addressograph

This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission medications. New medication prescribed on admission should be written on the physician’s order sheet.

Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records  Family Physician list
 Patient/resident recall  Family/caregiver recall
 MA  MAR from another facility  Other:______
 Community pharmacy list Pharmacy Name:______/ Diagnosis: (check all that apply)
□ IHD□ PVD□ Renal□ R.Arthritis □ Epilepsy
□ AFiB□ CVA Failure□ O.Arthritis □ Anxiety
□ CHF□ HTN□ COPD□ NIDDM □ Depression
□ Dyslipidemia□ MS□ IDDM
□ Other:
Weight: kg Allergies:
Height: cm
Medication History:
BPMH (Best Possible Medication History) / Physician Admission Orders:
To complete upon admission

Medication Name & Strength

(List all prescriptions and regularly taken OTC & PRN medications prior to admission). /

Dose

/

Route

/ Dosing Interval / Verified/Initial / Continue / Change / Hold / Discontinue / Reason for Change/Hold/Discontinuation
BPMH obtained by: ______Date/Time: ______
BPMH obtained by: ______Date/Time: ______ / Prescribing Physician:Date/Time:
Prescribing Physician: Date/Time:
Additional Medications Identified After Medication History Taken
( Please Fax Additions to Pharmacy)
Note: Any additions to
Preadmission medication list/s
received after list above is verified
Requires the physician orders
written on routine Physician
Orders (pink form).
BPMH obtained by: ______Date/Time: ______
BPMH obtained by: ______Date/Time: ______ / NOTE: Forall additional preadmission medications received after the BPMH has been completed still indicate intent regarding Continue, Discontinue, Change, Hold.

Please complete additional forms if additional space for medication list is needed.

Risk Score: (see tool form # ) Pharmacy Consult Recommended  No  Yes
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.

Disposition of Patient’s Medication on Admission:

 Locked up in nursing unit  Brought to hospital. Sent home with:  Not brought to hospital

Original Copy – On Chart Copy – to Pharmacy Fax to Pharmacy: Pages(s) of . 900-594

Western Regional Integrated Health Authority
*For LTC O’Connell/DVA Unit Use Only*
Pharmacy Referral-Medication Reconciliation
Risk Assessment Tool
**Keep this form with the Physician Orders** / Site:
 O’Connell LTC
 O’Connell Rehab
Patient Label/Addressograph
Patient Medication Risk Assessment Tool (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. warafin, low molecular weight heparin (e.g. tinzaparin, dalteparin, enoxaparin), 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.
If total score is > or = to 10, referral to Pharmacist is recommended.
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
Has the patient been transferred from Alternative Level of Care? / Automatic Referral to Pharmacy
Is the reason for admission clearly drug-related
(e.g. drug toxicity, non-compliance, polypharmacy)? / Automatic Referral to Pharmacy
Total Score

NOTE: Always fax to Pharmacy.

Original (white) – Patient’s ChartCopy of this form faxed – In-patient Pharmacy

900-594