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Ceptic Online - Medication Reconciliation

Hospital Admission - Medication Reconciliation Form

Patient Name: Ron Watson
DOB: 03/17/1997
Room: 1-395-C		 Allergies: Tetracycline (rash & labored breathing, 11 yrs ago) Immunization History:
Flu (last Dec), Tdap (16 yrs ago), No COVID-19 (suspicious of vaccine)
Community Rx Info: Walmart (Pine St.)
Rx Insurance: Aetna		 Social History: smokes 2 ppd x5 years, drinks 1-2 beers/weekend, no rec drugs, 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
Provigil (shift work disorder)
200 mg tab
by mouth
every morning
☐
yesterday at 9 pm
none
misses dose (1-2x/week)
    
Haloperidol (bipolar)
5 mg tab
by mouth
daily
☐
yesterday at 9 pm
weight gain
misses dose (1-2x/week)
    
Lithium carbonate (bipolar)
600 mg cap
by mouth
twice daily
☐
yesterday at 9 pm
mild stomach upset
misses dose (1-2x/week)
    
OTC - Excedrin Migraine
250/250/65 mg tab
by mouth
1 tab as needed for migraine
☐
5 days 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:
 
        Become easily distracted by the environment
 
2) Please apply the following confusion to how you are taking Provigil (shift work disorder):
 
        I am still taking this medication even though my doctor told me to stop it because I feel I need it