Medication Reconciliation

Hospital Admission - Medication Reconciliation Form

Patient Name: Spencer Norton DOB: 01/05/1961 Room: 4-124-A	Allergies: Sulfa antibiotics (severe hives, 10 yrs ago)	Immunization History: Flu (last Oct), Shingrix (x2 doses), Tdap (4 yrs ago), COVID-19 (Moderna, series complete + 2 boosters)
Community Rx Info: Walgreens (Oak St.) Rx Insurance: ExpressScripts	Social History: smoked 1 ppd x15 years but quit 5 years ago, drinks 1-2 beers/day, no rec drugs, 1-2 cups coffee/day

Complete Medication History Prior to Admission								Med Reconciliation
Medication Name	Strength	Route	Frequency	PRN?	Last Dose (date/time)	Adverse Effects	Adherence	Action	^*Reason for D,H,M
HCTZ/triamterene (HTN)	25 mg/37.5 mg cap	by mouth	every morning	☐	today at 7 am	none	never misses dose
Coreg (HTN)	12.5 mg tab	by mouth	twice daily	☐	today at 7 am	dizzy when standing (3x/month)	misses evening dose (1-2x/week)
Allopurinol (gout)	300 mg tab	by mouth	every morning	☐	today at 7 am	none	never misses dose
OTC - Naproxen	220 mg tab	by mouth	three times daily as needed for pain/HA	☐	1-2 weeks ago	mild stomach upset	N/A

Additional Notes:	Action Key: C = Continue ^*Must provide reason: D = Discontinue, H = Hold, M = Modify
Med history obtained by (sign and print):	Date: