CURRENT MEDICATIONS: DOSE ROUTE FREQUENCY
[Pages:1]Information from: Patient Legally Authorized Person (LAP) Family Patient's Medication List EMS/Transport Physician Office
Medication List from non-AH facility
Prior AH record
Other: ____________________________________
Allergies:___________________________________________________________________________
NO KNOWN CURRENT HOME MEDICATIONS
CURRENT MEDICATIONS:
Prescription / Over the counter / Vitamins / Herbals / Supplements / Neutraceuticals
DOSE
Quantity, strength
ROUTE
Oral, injectable, inhaler, topical
FREQUENCY
# of times per day, every day (no abbreviations)
HOSPITAL STAFF TO COMPLETE
( Day of procedure )
LAST DOSE: DATE / TIME
Box(es) not completed for dose, route or frequency ? information was not available. Should information become available ? complete as applicable.
____________________________________________ ____________ __________________________________________ ______________
Hospital Authorized Staff ? First Initial, Last Name, Title
Date / Time
Hospital Authorized Staff ? First Initial, Last Name, Title
Date / Time
NO changes to listed medications Your physician has ordered changes to some of your listed home medications as indicated below
DISCHARGE: NEW MEDICATIONS and/or CHANGES TO PREVIOUS MEDICATIONS:
MEDICATION(S)
DOSE
ROUTE
FREQUENCY
NEXT DOSE Rx
INSTRUCTIONS
This information was provided by you or your representative. If this information does not match your home records, or if you have any questions please contact the doctor that prescribed your medication(s).
____________________________________ __________________________ ____________________________________________
Patient Responsible Person Signature
Print Name / Relationship
Discharge: First Initial, Last Name, Title Date/Time
Check if applicable: Long term medication modified or added ? updated list provided to Next Provider of Care
OUTPATIENT MEDICATION LIST DH: Medication Reconciliation Document
602-1030 (1-15) MPC 72655
White ? chart Canary - Patient
Patient Label
Page _____ of _____
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