Transitions of Care Medication Review Note (Post-Discharge)

Encounter Date/Time: [date and time]

Encounter Type: [in-person / video / phone]

Clinician: [name, credentials, role]

Patient: [name, DOB]

Participants: [patient; caregiver name and relationship if present; interpreter if used]

Telehealth: [consent obtained; identity verified by method] (Omit if in-person)

Discharge Context

• Discharge Date & Facility: [date; facility name]
• Primary Discharge Diagnosis: [diagnosis or reason for hospitalization]
• Follow-up Status: [PCP appointment status; specialist appointment status; scheduled dates if known]
• Medication Information Sources: [discharge summary; pharmacy fill history; patient/caregiver report; pill bottles; other sources used]
• Missing Information: [what is unavailable and why] (Omit if not applicable)

Medication Reconciliation

(Compare discharge medication list to what patient is actually taking. Include prescriptions, OTC, supplements, and PRNs if discussed. Do not present unresolved discrepancies as finalized; label items pending confirmation.)

• Medication: [name] — Dose: [dose] — Route: [route] — Frequency: [frequency]

  Discharge Instructions: [as written on discharge medication list]

  Patient-Reported Actual Use: [what patient/caregiver reports taking]

  Status: [continue unchanged / new start / stopped / dose change / frequency change / not taking / unable to confirm]

  Discrepancy: [none / description] — Resolution: [resolved with education / prescriber notified / pending response / escalated / unable to resolve]

  Notes: [clarifying information or safety considerations] (Omit if not applicable)

• (Repeat medication block for each medication reviewed)

Summary: [total medications reviewed; key discrepancies identified; high-priority issues requiring follow-up or escalation]

Unreconciled Items: [medications unable to verify; attempts made; next steps] (Omit if not applicable)

Assessment

[Overall reconciliation status: completed/partially completed; number of discrepancies identified, resolved, and pending]

[Adherence barriers or access issues identified] (Note cost, fill status, prior authorization needs, administration difficulties. Distinguish confirmed vs patient-reported.)

[Adverse effects or safety concerns since discharge] (Include drug interactions, duplications, therapeutic omissions, time-sensitive risks.)

[Clinical prioritization] (Identify highest near-term risk items requiring expedited follow-up.)

[Recommendations] (If author is not a prescriber, label as recommendations and note whether prescriber approval was obtained for any changes.)

Plan

• Interventions Performed: [counseling topics; technique coaching; adherence tools provided; cost assistance or prior authorization steps]
• Communications & Escalations: [who contacted; method; clinical question; response received or pending]
• Updated Medication List Provided: [format and delivery method; key changes highlighted] (Omit if not provided)
• Follow-Up Plan: [next contact date; pending items to verify; upcoming appointments or labs relevant to medication safety]

If Unable to Reach Patient: [dates/times of outreach; methods; messages left; alternative contacts attempted; next outreach plan] (Omit if patient contact occurred)

Clinician Signature: [name, credentials, role]

Contributors: [names and roles of additional team members] (Omit if not applicable)