Form

Medication Reconciliation: Admission–Transfer–Discharge Form & Audit Checklist

An interactive admission-to-discharge medication reconciliation form combined with an embedded audit checklist. Collects structured medication lists (home, ED, inpatient), reconciled home list, counseling record, pharmacy verification, and audit sampling details so teams can save responses, measure fidelity, spot common errors, and prompt coaching.

Interactive Tool

Medication Reconciliation: Admission–Transfer–Discharge Form & Audit Checklist

This interactive form helps clinical teams capture medication lists across transitions (home, ED, inpatient) and record reconciliation decisions, pharmacy verification, patient counseling, and audit observations. Use one line per medication in the free-text lists (drug | dose | route | frequency | PRN?). The audit section supports periodic sampling and coaching prompts.

Enter the facility medical record number or local patient identifier.
Last, First. Helpful for quick human lookup during audits.
YYYY-MM-DD or local preferred format.
Select the transition where reconciliation occurred or was reviewed.
Date and time reconciliation activity occurred. Use local datetime format.
List medication entries one per line in this format: Drug | Dose | Route | Frequency | PRN? | Source (patient, family, med list, pharmacy). Example: Metformin | 500 mg | PO | BID | No | Patient+Bottle
List ED-recorded meds one per line. Include whether medications were continued, held, or changed on ED medication administration record.
List active inpatient medications one per line (same format as home meds). Include PRN entries and newly started meds.
Final reconciled list that will be communicated to patient/caregiver and used for discharge planning. One medication per line.
Briefly note key reconciliation decisions (e.g., stopped duplicate ACE inhibitor; clarified home insulin dose; changed PRN opioid instructions).
Select the role primarily responsible for this reconciliation action.
Time reconciliation was completed (use local time format).
Did pharmacy verify the reconciled list or medication orders?
Name or initials of the pharmacist who verified, if applicable.
Time of pharmacy verification, if completed.
Counseling includes explanation of changes, how to take meds, side effects to watch for, and follow-up plans.
Summarize the counseling provided and any materials given (e.g., teach-back performed, pill list printed).
Role of person who provided counseling.
When was counseling performed relative to the transition?
Mark yes if this encounter is selected for periodic audit sampling.
Select why this record is in the audit sample.
Useful for aggregate reporting and targeted coaching.
Enter 0 if none. Errors include omissions, duplications, wrong dose/frequency, unverified meds.
If yes, record coaching prompts below and notify the manager or educator per local process.
Suggest specific coaching points (e.g., confirm home insulin dosing with patient, use pharmacy med list, perform teach-back).
Examples: pharmacist post-discharge call, primary care med review, home health coordination.
List who will follow up, timeframe, and method (phone, clinic visit).
Person who completed the audit checklist portion.
Date the audit checklist was completed for this record.
Any other observations or contextual notes helpful for learning and improvement.
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