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Ceptic Online - Medication Reconciliation

Hospital Admission - Medication Reconciliation Form

Patient Name: Benny Lopez
DOB: 02/11/1968
Room: 3-298-B		 Allergies: Amoxicillin (severe rash, 8 yrs ago) Immunization History:
Flu (last Nov), Tdap (12 yrs ago), COVID-19 (Pfizer, series complete, no booster)
Community Rx Info: CVS (Walnut St.)
Rx Insurance: Caremark		 Social History: currently smokes 1.5 ppd x20 years, drinks 1-2 beers 3x/week, smokes marijuana 1-3x/month), 1 cup 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
Carbamazepine (seizure)
200 mg tab
by mouth
three times a day
☐
today at 8 am
none
misses noon dose (2-3x/week)
    
Dilantin (seizure)
100 mg cap
by mouth
2 caps twice daily
☐
today at 8 am
sore and swollen gums
never misses dose
    
Venlafaxine (GAD)
75 mg ER tab
by mouth
every morning
☐
today at 8 am
none
never misses dose
    
OTC - Bisacodyl
5 mg tab
by mouth
2 tabs as needed for constipation
☐
1 month ago
none
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:

IMPORTANT NOTE TO PATIENT:
 
1) Please adopt the following personality trait while speaking with the pharmacist:
 
        Act too interested and ask a lot of questions and go off on tangents
 
2) Please apply the following confusion to how you are taking Carbamazepine (seizure):
 
        I cut my dose in half because because it is too expensive