Forms Management Program
Acute Care Nursing
Directives
Form Title: Medication Reconciliation Record and Orders / Form #: 08930(2006-05)
Purpose: To provide complete and accurate documentation of the patient’s current home medication history and facilitate appropriate admission medication orders
General Principles:
- Use black or blue ink to complete the form.
- Patient identification must appear on every page
- All dates are to be in DTHR format, i.e. dd-mon-yy.
- All times are to be as per the 24 hr clock. i.e. hh:mm
- Only approved DTHR abbreviations are to be used.
Location in chart: Physician order section
Directives: Upon the patient’s arrival to hospital, the primary nurse is responsible for documenting the most accurate list possible of the patient’s current home medications – including drug name, dosage, route, and dosing interval.
This information is gathered and verified from the following sources –
- Patient, Family, Caregiver
- Electronic Health Record
- Prescription container
- Drug Store
- Other (specify)
Any updated home medication information obtained by subsequent caregivers (e.g. nurse, physician, or pharmacist) prior to the patient’s admission to hospital should also be documented on this reconciliation record.
Each individual must date, initial and sign any information they enter on this record.
The prescribing physician reviews each medication on this medication reconciliation record and orders the appropriate therapy for the patient’s admission to hospital.
This is indicated by a check mark in the appropriate column to:
-continue the home medication while in hospital as documented
-change the home medication (document change in blank space provided)
-discontinue the home medication (include reason for not ordering)
-comments field can be used by any discipline to clarify information specific to that medication
The prescribing physician MUST sign in the physician signature space once all medications have been addressed. Orders will not be filled by Pharmacy without a physician signature,signature or complete documentation of telephone orders for each medication, verified by an RN or Pharmacist.
Once the physician signs in the space provided, blank line items should be ruled out to avoid unauthorized medications from being added to the form. Any further clarification of home medications must be documented on a new order sheet.
The prescribing physician should include a reference to the completed medication reconciliation order form when writing admission orders.
New medication orders (ie: those that are NOT home medications) or any other orders not relating to home medications (ie: lab, diet orders, etc.) MUST be written on the regular physician’s order sheet.
A patient label must be affixed in the space provided on each page.
Allergies, including drug name and corresponding type of reaction, should be captured on this form. If more space is required, this should be indicated with a reference to the information.
Height and weight should be documented – either as “actual” or “stated”. .
-use Kg and cm if weighing/measuring the patient
-ALL measurements must be documented in metric units (DTHR Policy CC-VIII-25)
Number of pages should be indicated – even if only one page exists.
A copy of the signed, completed form is to be sent to Pharmacy via the pneumatic tube system when the medication orders are processed.