Medication & Supplement Reconciliation and Safety Review Note

Date/Time: [Date and time of documentation]

Patient: [Full name and identifier per local policy]

Clinician: [Name, credentials, role]

Encounter Type: [outpatient / inpatient / transition-of-care / telehealth / phone]

Reason for Reconciliation: [One-line summary of reason]

Sources & Verification

Sources used: [Sources consulted, e.g., patient interview, medication bottles/photos, pharmacy fill history, prior EHR lists, discharge summary, caregiver report] (Include relevant identifiers such as pharmacy name, date ranges reviewed, or caregiver relationship.)

Verification Level: [Verified / Partially verified / Unverified]

Limitations/Missing information: [Description of uncertainties or gaps, if any]

Resolution plan: [Specific actions to obtain missing data, responsible party, and timeframe] (Omit if no limitations identified.)

Current Regimen (As Taken)

(Include prescription medications, OTC products, vitamins/minerals, herbals, and dietary supplements actually taken. Use generic names; add brand/manufacturer for supplements or narrow therapeutic index drugs. Do not infer unknown details—use "unknown strength" or "unknown dose" and document plan to clarify. If patient takes no medications or supplements, state this explicitly and omit table.)

Agent (generic; brand if relevant)	Form/Strength	Dose	Route	Frequency/Timing	Indication	Adherence/Notes
[Agent name]	[Form/Strength]	[Dose amount]	[Route]	[Frequency/Timing]	[Indication]	[Adherence status, administration notes, or unverified multi-ingredient contents]

Allergies & Adverse Reactions

(List each known allergy, adverse drug reaction, or intolerance. If none verified, document "NKDA" or "No known drug allergies.")

• [Substance]: [Reaction description or "reaction unknown"], [Severity], [Approximate date if known], [documented / patient-reported]. [Cross-reactivity considerations if applicable]

Reconciliation & Safety Review

Discrepancies identified: (Document differences between patient's actual regimen and other sources. If none identified, state explicitly and omit table.)

Item	Discrepancy Type	Description & Clinical Significance	Action Taken/Recommended	Status
[Medication/Supplement]	[omission / duplication / wrong dose / wrong frequency / formulation mismatch / other]	[Brief description and clinical significance]	[Correction made or recommendation; responsible party]	[resolved / pending / needs prescriber confirmation]

Safety screening method: [EHR interaction checker / pharmacy database / manual review / combination]

Clinically meaningful safety findings: (Include only actionable findings. If none, state: "No clinically significant interactions or safety issues identified.")

• [Issue]: [Clinical concern, e.g., bleeding risk, serotonergic toxicity, QT prolongation, anticholinergic burden, sedation/falls, CYP interaction, therapeutic duplication, contraindication]. [Mitigation plan]

Adherence concerns impacting safety: (Omit if none identified.)

• [Barrier or issue, e.g., cost, access, side effects, complexity, administration technique]: [Plan to address]

Plan

Changes Made: (Omit if no changes made.)

• [Started / Stopped / Modified]: [Medication/Supplement], [What changed], [Brief rationale], [Authorized by]

Counseling Provided:

• [Key education points discussed] (Note if teach-back performed and comprehension confirmed.)

Materials: Updated medication list provided to patient: [yes / no]; format: [printed / portal / secure message]

Monitoring: (Omit if no specific monitoring required.)

• [Parameter to monitor], [Timing/frequency], [Responsible party], [Action if abnormal]

Follow-Up:

• [Next planned contact and timing]
• [Pending items and responsible party] (Omit if none.)
• [Return precautions tailored to identified risks]

(If critical information remains unconfirmed, document uncertainties, interim risk-mitigation steps, and concrete plan to resolve. Omit non-applicable sections rather than leaving empty.)