nursing medication reconciliation

Patient Information Section

Confirm patient's full name and date of birth

Verify patient's medical record number

Ensure patient's current location (ward, room number)

Medication History Section

Review patient's previous medication history

Check for any recent changes in medication regimen

Verify any ongoing medication allergies or adverse reactions

Ensure accuracy of medication history information provided by patient or caregiver

Current Medication Orders Section

Obtain and review current medication orders from healthcare provider

Compare medication orders with patient's medication history

Check for any discrepancies or inconsistencies in medication orders

Ensure all necessary details are included in medication orders (dosage, frequency, route)

Medication Supply Section

Verify availability of all prescribed medications

Check medication expiration dates

Ensure proper storage conditions for medications

Identify any medication shortages or stock-outs

Medication Administration Section

Confirm patient's understanding of medication regimen

Ensure patient's ability to self-administer medications, if applicable

Review any special considerations or precautions for specific medications

Check for any contraindications or interactions with other medications

Documentation Section

Record all medication reconciliation activities and findings

Document any discrepancies or issues identified during the process

Report any medication reconciliation errors or concerns to appropriate healthcare professionals

Ensure proper documentation of medication changes or adjustments

Follow-up Section

Schedule any necessary follow-up appointments or consultations

Communicate medication changes or adjustments to relevant healthcare providers

Ensure patient and/or caregiver receive appropriate education and instructions regarding medication regimen

Document any recommendations or suggestions for improving medication reconciliation process

Note: This is a general outline for a nursing medication reconciliation checklist. The specific items and order may vary depending on the healthcare facility's protocols and guidelines.