Medication Reconciliation Note (Pharmacist)

Medication Reconciliation — Transitions of Care

Date/Time: [date and time reconciliation performed]

Setting: [Admission / Discharge / Clinic / Transfer]

Location/Service: [unit and care team]

Pharmacist: [name, credentials]

Status: [Complete / Partial / Unable] (If Partial or Unable, state what could not be verified and the follow-up plan with responsible party and timeframe.)

Sources and Verification

(List all sources used to obtain the Best Possible Medication History. For each source, include date/time accessed and reliability assessment. Label any unverified medication as "patient-reported only.")

• Source: [source type] — Date/Time: [date/time] — Reliability: [high / moderate / low]
• (Add additional sources as needed.)

Allergies/ADRs: [Allergies reviewed—no changes / NKDA confirmed / Updated: allergen, reaction, severity]

Best Possible Medication History (BPMH)

(Document what the patient actually takes, including prescriptions, OTCs, supplements, herbals, inhalers, topicals, and injectables. Use generic names. Use leading zeros for doses under 1; avoid trailing zeros and error-prone abbreviations. Enter explicit placeholders for unknowns rather than omitting entries.)

Medication (generic)	Strength	Dose	Route	Frequency	Indication	Last dose taken	Adherence notes	Verification status
[medication name]	[strength]	[dose]	[route]	[frequency]	[indication if known]	[date/time]	[notes if relevant]	[verified / patient-reported only]
(Add rows for each medication.)

Discrepancies and Resolution

Reconciliation target: [admission orders / discharge medication list / ambulatory medication list]

(Compare BPMH to reconciliation target. For each discrepancy, document type, intent classification, action taken, and outcome. If none found, state "No discrepancies identified.")

• Medication: [name] — Discrepancy: [type] — Intent: [intentional / unintentional]

  • Action: [action taken]
  • Contacted: [person/role] via [method] on [date/time]
  • Outcome: [resolved / unresolved] (If unresolved, document reason and follow-up plan.)
• (Repeat for each discrepancy, or state "No discrepancies identified.")

Reconciled Medication List

As-of: [date/time]

(For Admission or Clinic: present reconciled home medication list or reference EHR location and summarize changes. For Discharge: organize by category below.)

Continue

• [medication, strength, dose, route, frequency] — [indication] — [instructions if applicable]

Start

• [medication details] — [indication] — [duration/stop date] — [rationale]

Stop

• [medication] — [rationale] — [effective date]

Change

• [medication] — [change description] — [rationale]

Hold

• [medication] — [reason] — [restart criteria and timing]

Education and Handoff

• Education provided to: [patient / caregiver] — Format: [verbal / written list / both]
• Key topics: [topics covered, prioritizing new, stopped, or changed medications]
• Teach-back: [successful / partial / unable] — Barriers/Mitigation: [barriers identified and plan if applicable]
• Notifications: [parties notified] via [method] on [date/time] — Status: [completed / attempted] (If unable to reach, document attempts and fallback plan.)