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Guideline Medication History and Reconciliation Guidelines for the use offers Document NumberGE2012 027Publication Date26 June 2012Intranet location/clinical Medication / Drugs / PharmacySummaryGuidelines

How to fill out medication history and reconciliation

How to fill out medication history and reconciliation

1. Step 1: Gather all necessary information about the medications the patient is currently taking, including the name, dosage, frequency, and route of administration.
2. Step 2: Verify the medication information with the patient and ask if there are any changes or additional medications not listed.
3. Step 3: Document the medication history accurately in the patient's medical record or medication reconciliation form.
4. Step 4: Identify discrepancies or potential drug interactions by comparing the medication history with previous records or consulting a reliable drug reference source.
5. Step 5: Resolve any discrepancies or drug interactions by communicating with the prescribing healthcare provider or pharmacist.
6. Step 6: Update the medication list based on the reconciliation process and ensure it is shared with other healthcare providers involved in the patient's care.

Who needs medication history and reconciliation?

1. Patients who are admitted to a healthcare facility, such as hospitals or nursing homes, where multiple healthcare providers are involved in their care.
2. Patients with complex medical conditions who may be taking multiple medications from different healthcare providers.
3. Elderly patients who often have more complex medication regimens and are at a higher risk for medication-related problems.
4. Patients transitioning between different healthcare settings, such as being discharged from a hospital to home care or transferring between different healthcare facilities.
5. Patients with a history of medication non-adherence or medication-related problems.

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