Medication Review & Deprescribing Note

Date/Time: [Date and time of review]

Provider: [Name, credentials, role]

Patient: [Name, identifier, DOB]

Reason for Review: [polypharmacy / falls risk / post-discharge reconciliation / anticholinergic burden / other]

Primary Prescriber(s): [Names, specialties, contact] (Include only if coordinating with other providers)

Patient Goals & Context

[Patient-stated priorities and what matters most regarding medications] (Use brief quotes when helpful. Note participants in discussion if applicable. If goals cannot be obtained, document why and who can provide them later.)

Medication Reconciliation

Sources: [List sources used: patient report, caregiver, pill bottles, pharmacy records, facility MAR, discharge summary, etc.]

Confidence: [Completed / Partial] (If Partial, specify which items are unverified)

Adherence notes: [Describe "as taken" vs "as prescribed" discrepancies] (Only include if discrepancies present)

Current Medication List (Before)

(Include all prescription, OTC, supplements, herbals, and PRN medications. Flag unverified items with "[unverified]" in Notes.)

Medication	Dose/Route	Frequency	Indication	Notes
[Medication name]	[Dose / Route]	[Frequency]	[Indication]	[Adherence, side effects, prescriber if relevant]

Review Findings

(Organize by medication or therapeutic class, addressing highest-risk items first. Omit detailed findings for medications that are straightforward to continue.)

• [Medication or class]: [Indication validity and alignment with patient goals; patient-specific safety concerns such as falls, cognition, renal function, interactions; explicit justification if continuing a potentially inappropriate medication]
• [Additional medications as needed]: [Key risk/benefit points; safety considerations; justification if continuing despite risk]

Plan

Medication Changes

(If no changes made, document "No medication changes today" with brief explanation.)

• [Medication]:
  • Action: [Stop / Taper / Dose change / Switch / Start / Hold]
  • Rationale: [Brief benefit-harm statement tied to patient goals]
  • Taper schedule: [Stepwise doses and intervals; expected vs concerning symptoms; rescue plan] (Include only if tapering)
  • Monitoring: [What to monitor, who monitors, when to contact clinic]

Sequencing note: [Order of changes and reasoning] (Include only if multiple changes planned)

Coordination: [Actions taken: pharmacy notified, other prescribers contacted, updated list provided to patient/caregiver]

Updated Medication List (After)

(List all active medications after today's changes.)

Medication	Dose/Route	Frequency	Indication	Status	Effective Date
[Medication name]	[Dose / Route]	[Frequency]	[Indication]	[Continue / Stop / Taper – current step / Changed dose / New]	[Date]

Follow-up

Reassessment: [Timeframe, typically 2–4 weeks during active taper] (Specify earlier if safety concerns)

Monitoring responsibilities: [Who monitors what; thresholds for contacting clinic or seeking urgent care]

Outstanding items: [Pending records, consultations, or information to be confirmed] (Use placeholders like "[pending pharmacy records]" for unresolved items)