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Ceptic Online - Medication Reconciliation

Hospital Admission - Medication Reconciliation Form

Patient Name: Lisa Sandoval
DOB: 05/16/1976
Room: 6-743-A		 Allergies: Carbamazepine (severe rash, 20 yrs ago) Immunization History:
Flu (last Oct), Tdap (12 yrs ago), COVID-19 (Pfizer, series complete, no booster)
Community Rx Info: Rite Aid (Juniper St.)
Rx Insurance: Humana		 Social History: smoked 2 ppd x5 years but quit 15 years ago, drinks 1-2 rum & coke/week, smokes marijuana 1-2x/week), 1 energy drink/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
Metformin (DM2)
1000 mg tab
by mouth
twice daily
☐
yesterday at 8 pm
stomach upset, diarrhea
misses evening dose (1-2x/week)
    
Quinapril (DM2)
10 mg tab
by mouth
once daily
☐
yesterday at 8 am
none
never misses dose
    
Pravastatin (DM2)
40 mg tab
by mouth
once daily
☐
yesterday at 8 am
occasional muscle pain
never misses dose
    
OTC - Chromium
500 mcg cap
by mouth
once daily for diabetes
☐
yesterday at 8 am
none
never misses dose
    
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:
 
        Mumble when you speak and mispronounce the names of drugs
 
2) Please apply the following confusion to how you are taking Metformin (DM2):
 
        I cut my dose in half because I am feeling better