Home Medication Reconciliation Form

Winter Haven Hospital
Winter Haven, Florida, USA


In response to the Joint Commission National Patient Safety Goals, this form was developed to obtain a list of "medications as at home" prior to admission so that medications can be reconciled. It has been used extensively in all outpatient areas and on a medical/surgical unit. The form prompts the information collector for completeness, yet is organized for ease of use by nurse and physician.



This NCR (carbonless) form was created so that two copies of the completed form are generated: one for the pharmacy and the other for the patient (given to the patient at outpatient discharge). A demand-printed computer listing of current medications from the pharmacy also has identical check boxes as this medication reconciliation form so that it serves as the inpatient transfer/discharge form.


Form last modified April 2006.

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