Nurse Template
Medication Reconciliation Form
A professional Nurse template for healthcare professionals.
About this template
This Medication Reconciliation Form is an essential tool that helps accurately track and manage a patient's medication list upon admission, transfer, or discharge, preventing medication errors. Ideal for hospital wards, clinics, and care homes, it provides clear sections for current home medications, new prescriptions, and discontinued drugs. With Heidi, this form captures medication details from clinician-patient conversations and existing records, ensuring all fields are meticulously completed for a robust and reliable medication history.
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Medication Reconciliation Form PDF
Patient Name: [Sarah Jenkins]
Date of Birth: [15/03/1978]
NHS Number: [A1234567]
Date of Reconciliation: [1 November 2024]
Reason for Reconciliation: [Admission to ward for pneumonia]
Source of Medication Information: [Patient interview, GP record, previous hospital discharge summary]
**Current Home Medications**
| Medication Name | Dose | Route | Frequency | Last Taken (Date/Time) | Indication | Special Instructions |
|---|---|---|---|---|---|---|
| Ramipril | 5mg | Oral | Once daily (morning) | 1 November 2024 (08:00) | Hypertension | Take with water |
| Atorvastatin | 20mg | Oral | Once daily (evening) | 31 October 2024 (20:00) | Hypercholesterolaemia | |
| Salbutamol Inhaler | 100mcg | Inhaled | PRN (up to 4 puffs QDS) | 1 November 2024 (10:30) | Asthma | As needed for breathlessness |
| Paracetamol | 500mg | Oral | PRN (up to QDS) | 31 October 2024 (18:00) | Pain/Fever | Max 4g in 24 hours |
**New Medications Started During Current Admission**
| Medication Name | Dose | Route | Frequency | Start Date/Time | Indication | Special Instructions |
|---|---|---|---|---|---|---|
| Amoxicillin | 500mg | Oral | TDS | 1 November 2024 (14:00) | Community Acquired Pneumonia | Complete full course |
| Prednisolone | 30mg | Oral | Once daily | 1 November 2024 (14:00) | Acute asthma exacerbation | |
**Medications Discontinued During Current Admission**
| Medication Name | Dose | Route | Frequency | Discontinuation Date/Time | Reason for Discontinuation |
|---|---|---|---|---|---|
| N/A | | | | | |
**Discrepancies Noted and Action Taken**
* **Discrepancy:** Patient reported taking Ramipril 10mg daily, but GP record shows 5mg daily.
* **Action:** Contacted GP practice, confirmed 5mg is correct dose. Patient counselled on current prescribed dose. Updated medication list accordingly.
**Allergies:**
* Penicillin (rash)
* Codeine (nausea)
**Medication History Verified By:** [Nurse Emily Davis]
**Signature:** [E. Davis]
**Date:** [1 November 2024]
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Specialty
Nurse
Used
16 times
Type
Form Template
Last edited
1/25/2026
Created by
Heidi Team