Medication Reconciliation Note (OTC and Supplement/Herbal Products)

Date/Time: [Date and time of reconciliation]

Author/Credentials: [Name, credentials, role]

Encounter Context: [Setting; in-person / telehealth; location if relevant]

Reconciliation Trigger: [annual review / post-discharge / new patient intake / pre-procedure / adverse effect evaluation / other: specify]

Reconciliation Status: [Complete / Partial / Unable to complete] (If Partial or Unable, include reason and follow-up plan with responsible party and timeline.)

Sources and Verification

Primary historian: [patient / caregiver / guardian / other] (Include name and relationship when applicable.)

Secondary sources consulted:

• [Medication bottles/packaging] (Include date reviewed.)
• [Patient-maintained list or app] (Name of app or document; date last updated.)
• [EHR medication list] (Date/time accessed.)
• [Pharmacy fill history] (Pharmacy name(s); date range reviewed.)
• [Recent discharge summary] (Facility; date.)
• [Specialist notes] (Specialty; clinician; date.)
• [Other: specify]

Overall verification level: [verified with two or more sources / patient report only / external record only] (Briefly justify.)

Data quality notes: [Uncertainties or limitations impacting safety or accuracy, e.g., patient unsure of strengths, combination products with unclear ingredients, duplicate similar products, language or health literacy barriers]

Limitations: [If no secondary source available, state verification is limited and outline plan to obtain additional sources.]

Patient Context and Allergies

Medication safety context: [Pregnancy/lactation status if applicable; renal/hepatic impairment; anticoagulation/bleeding risk history; recent procedures or hospitalizations; high-alert medication use; other factors directly affecting reconciliation decisions] (Do not restate full medical history.)

Allergies, adverse reactions, and intolerances: (Document each item; include excipient/ingredient sensitivities.)

• Substance/ingredient: [Name] — Reaction: [Type/description] — Severity: [mild / moderate / severe] — Approx timeframe: [Date or unknown] — Classification: [true allergy / intolerance / side effect / contraindication] — Source: [patient / record / other] — Confidence: [high / medium / low]

• (Repeat as needed.)

(If allergy history was not obtained, state the reason and plan to obtain. Do not default to NKDA unless explicitly confirmed.)

Best Possible Current Medication List

(Capture what the patient is actually taking prior to reconciliation. If use differs from label or EHR, document actual regimen and note discrepancy. If a category has no items, explicitly record "None reported"—do not omit the category.)

Prescription Medications

• Product: [Generic name (Brand if relevant)] — Dosage form: [form] — Strength/concentration: [value or unknown]

  Route: [route] — Dose per administration: [dose] — Frequency/timing: [scheduled times or PRN; include days of week if intermittent] (For PRN, include indication and maximum daily dose.)

  Indication (patient-stated): [purpose] — Approx start date: [date or unknown]

  Adherence: [taking as directed / partial / not taking] (Include barriers or reasons if not taking as directed.)

  Side effects/tolerability: [reported concerns / denies]

  Source(s) for this entry: [e.g., bottle, patient report, EHR, pharmacy history] — Confidence: [high / medium / low]

  Discrepancy note: [If actual use differs from label/EHR, describe difference.] (Omit if none.)

• (Repeat for each prescription medication. If none, state "None reported.")

OTC Medications

• Product: [Generic name (Brand if relevant)] — Dosage form: [form] — Strength/concentration: [value or unknown]

  Route: [route] — Dose: [dose] — Frequency/timing: [schedule or PRN with indication and max daily dose]

  Indication (patient-stated): [purpose] — Approx start date: [date or unknown]

  Adherence: [taking as directed / partial / not taking] — Side effects/tolerability: [concerns / denies]

  Source(s): [source(s)] — Confidence: [high / medium / low]

  Discrepancy note: [If applicable] (Omit if none.)

• (Repeat as needed. If none, state "None reported.")

Vitamins and Minerals

• Product: [Name] — Dosage form: [form] — Strength: [value or unknown]

  Route: [route] — Dose: [dose] — Frequency/timing: [schedule or PRN with indication and max daily dose]

  Indication (patient-stated): [purpose] — Approx start date: [date or unknown]

  Adherence: [taking as directed / partial / not taking] — Side effects/tolerability: [concerns / denies]

  Source(s): [source(s)] — Confidence: [high / medium / low]

  Discrepancy note: [If applicable] (Omit if none.)

• (Repeat as needed. If none, state "None reported.")

Supplements/Herbal Products

• Product: [Name] — Active ingredient(s)/species: [list or unknown] — Combination product: [yes / no / unknown]

  Preparation type: [tea / tincture / capsule / topical / drops / other] — Strength/concentration: [value or unknown]

  Route: [route] — Dose: [dose] — Frequency/timing: [schedule or PRN with indication and max daily dose]

  Indication (patient-stated): [purpose] — Approx start date: [date or unknown]

  Adherence: [taking as directed / partial / not taking] — Side effects/tolerability: [concerns / denies]

  Quality/label concerns: [unknown strength / proprietary blend / homemade preparation / other / none]

  Label vs actual use: [Describe any differences] (Omit if none.)

  Source(s): [source(s)] — Confidence: [high / medium / low]

• (Repeat as needed. If none, state "None reported.")

Recently Stopped or Changed (past 30–90 days)

(Include only if clinically relevant to current reconciliation.)

• Medication/product: [Name] — Change: [stopped / dose changed / frequency changed / formulation changed]

  Date of change: [date or unknown] — Reason: [side effect / lack of efficacy / completed course / interaction / cost / access / other] — Directed by: [clinician / patient / other]

  Follow-up needed: [monitoring, replacement therapy, or none]

• (Repeat as needed. Omit section entirely if no relevant recent changes.)

Discrepancies and Safety Concerns

(Document problem-oriented issues including unintended discrepancies between sources, duplications, unclear directions, wrong dose, and outdated medications still listed. Flag high-risk patterns such as multiple acetaminophen-containing products, multiple NSAIDs, or multiple sedatives.)

• Issue: [Description of discrepancy or safety concern]

  Involved item(s): [Medication(s)/product(s)] — Risk: [Clinical significance]

  Clarification needed: [Specific question(s) to answer, e.g., "Dose unknown—patient will bring bottle to next visit"]

  Verification plan: [Who will verify; method; deadline]

  Status: [open / resolved] — Resolution date: [date if resolved]

• (Repeat per issue. If no discrepancies identified, state "No discrepancies identified.")

Interaction and Safety Review

(Summarize clinically relevant interactions only—avoid exhaustive interaction-checker output.)

• Interaction pair: [Agent A + Agent B] — Clinical risk: [brief description] — Recommended action: [monitor / adjust dose / separate dosing / counsel / discontinue]
• (Repeat for additional clinically significant interactions. If none identified, state "No clinically significant interactions identified.")

Condition-specific precautions: [e.g., NSAID use with renal impairment; bleeding risk with antiplatelet plus certain supplements; other relevant cautions] (Omit if none.)

Side effects reported and suspected causality: [Symptom] — Suspected agent(s): [list] — Causality: [suspected / confirmed] — Plan: [monitor / modify / discontinue / other] (Omit if no side effects reported.)

Reconciled Medication Plan

(Assign exactly one disposition to every medication and supplement discussed.)

Continue (no change)

• [Medication/product name] — [dose, route, frequency, timing] — Indication: [reason]
• (List each item continued without change.)

Modify

• Item: [Name]

  Prior regimen: [brief] — Updated regimen: [explicit directions]

  Rationale: [clinical reason] — Monitoring/Counseling: [labs, vitals, symptoms, timing]

  Effective date: [date]

• (Repeat per modified item.)

Stop/Discontinue

• Item: [Name] — Effective date: [date]

  Rationale: [interaction risk / adverse effect / no longer indicated / duplicate therapy / other]

  Taper required: [yes / no] (If yes, provide taper instructions.) — Alternative: [if applicable]

• (Repeat per discontinued item.)

Start

• Item: [Name] — Indication: [reason]

  Directions: [dose, route, frequency, timing] — Duration: [time-limited duration or ongoing]

  Key counseling: [administration, side effects, interactions, when to seek care] — Monitoring: [labs, vitals, symptoms, timing]

• (Repeat per new item.)

Pending Verification

• Item: [Name] — Temporary plan: [hold / continue as currently taken / other]

  Details to verify: [specifics: strength, dose, route, frequency, indication, start date, prescriber]

  Responsible party: [patient / caregiver / clinician / pharmacy] — Deadline: [date/time]

• (Repeat per pending item. Omit section if none pending.)

(If no changes after reconciliation, state explicitly: "No changes after reconciliation.")

Patient Education and Follow-up

• Updated reconciled medication list provided via: [paper / portal / after-visit summary] — Date/time: [date/time]
• Counseling provided: [Avoid duplicate acetaminophen and NSAID products; bring bottles or updated list to each visit; notify clinicians before starting new supplements/herbals; key administration tips; red flag symptoms and what to do]
• Care coordination: [Notifications sent to other prescribers/pharmacies; prescriber approvals obtained for prescription changes; summaries sent to care team] (Omit if none.)
• Follow-up/monitoring plan: [Labs, vitals, symptom checks, interaction monitoring] — Timeframe: [date/interval] — Plan to complete pending verification: [who, how, by when]

Signature

[Clinician signature], [Credentials] — [Date], [Time]