Medication Reconciliation Review: Data Collection Form

Luther Midelfort — Mayo Health System
Eau Claire, Wisconsin, USA


This form was designed at Luther Midelfort Hospital for staff to use as part of the medication reconciliation review process. The Medication Reconciliation Review provide instructions for conducting the review of closed patient records. Data recorded with the Medication Reconciliation Form can be aggregated and monitored over time, as part of an ongoing improvement effort. Detailed instructions for using the form are provided in the Medication Reconciliation Review.



Before using this form, an organization must first implement a medication reconciliation review process with clear procedures and training for relevant personnel. This form is a sample of many possible forms that can be used, once the process is in place, to assist nursing personnel in conducting medication reviews. It is recommended that the organization regard this form as a sample only, reviewing and making modifications to it as appropriate for the needs of the individual organization and nursing unit.

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