Discharge Medication Counseling Note

Date/Time of Counseling: [Date and time of counseling]

Discharge Date: [Discharge date if different from counseling date, or N/A]

Author: [Author full name, credentials, role]

Patient: [Patient full name and identifiers per local policy]

Participants: [Patient and/or caregivers with relationship; interpreter and language if used]

Counseling Modality: [in-person / phone / video / caregiver-only]

Clinical Context

[Brief hospitalization context relevant to medication changes, including why the regimen changed, pertinent diagnoses or procedures, and patient-specific factors affecting counseling such as health literacy, cognitive status, sensory impairments, language needs, or swallowing limitations] (1–3 sentences. If unknown, state that clinical context was not available at time of counseling.)

Medication Changes Reviewed

Discharge medication list status: [final / draft-pending] (If draft, document that the patient/caregiver will be updated if changes occur.)

New Medications

(If none, document "None.")

• [Medication name] — [dose], [route], [frequency]

  • Indication: [Purpose in plain language]
  • Duration: [Stop date or ongoing]
  • Key instructions: [Administration timing, food interactions, spacing from other medications]
  • Red-flag symptoms: [Symptoms requiring urgent action with thresholds for seeking care]
  • (Include missed/extra dose instructions, critical interactions, or device technique only when clinically important.)

Changed Medications

(If none, document "None.")

• [Medication name] — [Indication in plain language]

  • Previous regimen: [Prior dose/route/frequency] (Document "Unknown" if not verified.)
  • New regimen: [Current dose/route/frequency]
  • Reason for change: [Reason per clinician or discharge orders]
  • Stop instruction: [Explicit instruction to discontinue old regimen]
  • (Include red-flag symptoms, missed/extra dose instructions, or critical interactions only when clinically important.)

Discontinued Medications

(If none, document "None.")

• [Medication name]

  • Reason stopped: [Reason]
  • Remaining supply: [discard / do not discard / return to take-back program]
  • (Include alternative therapy only if applicable.)

High-Alert Medication Safety Details

(Include only if anticoagulants, insulin, opioids, hypoglycemics, or sedatives are present. Otherwise omit this section.)

• [High-alert medication name]

  • Exact dosing schedule: [Timing, units, delivery method]
  • Missed/extra dose plan: [What to do, what to avoid, when to call]
  • Critical interactions: [OTCs, supplements, alcohol, activity restrictions as applicable]
  • Monitoring plan: [What to monitor, target ranges, who orders tests, when due, who reviews results]
  • Device technique: [Steps taught, return demonstration observed yes/no, errors corrected] (Include only if applicable.)
  • Safety counseling: [Storage, disposal, risk mitigation such as naloxone for opioids] (Include only if applicable.)

Education and Comprehension Assessment

Education provided: [Summary of education organized by medication change, including purpose, administration, expected effects, side effects, red-flag symptoms, and missed dose guidance as clinically relevant]

Materials provided: [Updated medication list / calendar / handouts / none] (Specify language and whether written instructions were reviewed.)

Teach-back performed: [yes / no]

• If yes: [Who performed teach-back (patient/caregiver), what was asked, observed explanation or demonstration, misunderstandings identified and corrections made]
• If no: [Reason not performed and mitigation steps taken] (Do not document that the patient "understands" without an observed confirmation method.)

Access and Follow-Up Plan

Pharmacy: [Pharmacy name and location where prescriptions were sent]

Receipt confirmed: [yes / no / pending] (If not confirmed, note planned follow-up.)

Barriers addressed: [Prior authorization, cost, insurance, transportation, stock issues and resolutions] (Document "None identified" if applicable.)

Meds-to-beds: [arranged / not available / declined / not applicable]

Adherence supports: [Pill organizer, medication calendar, reminder system, caregiver assistance, formulation accommodations as applicable]

Red-flag symptoms reviewed: [Key symptoms tied to new/changed medications]

Escalation instructions: [Who to call, when to seek urgent care or ED; note if written instructions were reviewed]

Counseling outcome: [completed / partial / declined / unable to reach]

Remaining questions: [Unresolved questions or concerns, or "None stated"]

Follow-up plan: [Upcoming appointments relevant to medications, lab monitoring with responsible parties and timing, planned post-discharge outreach]

Unknowns: [Information not verified such as prior regimen or preferred pharmacy, with steps to clarify] (Omit if none.)