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Microsoft word - homemedlist.doc
Iredell Memorial Hospital --- Statesville, NC
HOME MEDICATION LIST / PHYSICIAN DISCHARGE INSTRUCTIONS
Med List Continued - Page # __________
Patient Medication List
MAR from facility --
Attached (ED only)
(check all that apply)
Retail Pharmacy __________________________________
Patient recal or Family / S.O. recall: _________________________ (name)
Regular or Family Physician
Note: Medications cannot be altered after they have been ordered. Once ordered, note any clarifications in “Comments” column or on an additional form. To order
different dosage, frequency, etc., please use separate physician order sheet.
List Only Medications Patient is Currently Taking
DO NOT USE:
Yes = Order as listed
qd, QD, qod, QOD, u, U, MS, MSO4, MgSO4, IU, g, Trailing zeros, Leading decimals
No = Do not order
= See Physician
(Include SR, SL, SA, etc.) (mg, ml, # tabs) (if not po) (Indication for prn’s)
with: ________________ List Obtained By: _______________________________, RN ____________ Add’l Info. Obtained By: ____________________________, RN ____________
Admission Orders: Physician Signature: ______________________________________________________________ Date/ Time: __________________
List Reconciled By: ______________________________________________, RN Date / Time:___________________________
Discharge Date: __________________ Discharge After _________________________________ (Procedures, seen by consult, etc.)
Home Health for _______________________________________________________________________
Return to Work or School: ________________________
As before Admission
Special Instructions / Wound Care
Follow-up Appointment(s): _______________________________ _________________________________ _____________________________
New Medications / Changes to home medications:
Forward copy of discharge instructions to:
Physician Signature at Discharge: ________________________________________________________ Date / Time ___________________________
Instructions for Medication Reconciliation on Inpatient Unit:
a. Review med list with patient / family b. Attempt to clarify any incomplete listings (OK to edit as long as medication hasn’t been ordered) c. When list is complete and all medications have been addressed (“Yes”, “No”, “SPO” or note of
explanation by each med), sign “Reconciled By” line at bottom of form.
a. Obtain complete list of patient’s medications (Include Rx and OTC meds, vitamins, and herbal
b. Review list with physician when obtaining admission orders. Circle “Yes” by medication if
physician wants to order as listed. Circle “No” by medication if physician does not want to order medication. Circle “SPO” by medication if medication ordered differently or addressed on physician order sheet.
c. If Admission orders already received, compare list to physician orders & utilize key to complete
“Review of Physician Order/Comments” column. Indicate whether med already ordered exactly as listed (9), not ordered (N), or ordered differently (D).
d. Document any explanation, based on admitting diagnosis, explaining meds not ordered or ordered
e. Call physician re. any meds not ordered (N) or ordered differently (D) that have not been explained. f. Document result of physician contact in Physician Order section:
Yes = Continue med as listed on home med list
SPO = See Physician Orders. Circle this option when medication is ordered on a separate
physician order sheet (e.g., med ordered differently or listing incomplete but med
g. Scan list to pharmacy and place in MD Discharge Orders Section when all meds have been
Example #1: Home medication, K-dur, was not ordered for patient admitted with hyperkalemia. Nurse would
note “hyperkalemia” in “Comments” column. The physician would not need
to be contacted
about this medication.
Example #2: Home medication, Coumadin, was not ordered for patient admitted with Elevated INR. Nurse
would note “elevated INR” in “Comments” column. The physician would not need
contacted about this medication.
Example #3: Home medication, Lasix 20 mg po daily, changed to Lasix 40 mg IV q12h in admission orders for
patient admitted with pulmonary edema. Nurse would note “pulmonary edema” in “Comments”
column. The physician would not need
to be contacted about this medication.
Example #4: Home medication, Lipitor 80 mg po, not ordered for patient admitted for left knee
replacement. The physician would need
to be contacted about this medication.
Example #5: Patient admitted with pneumonia states they take Coumadin 5 mg po daily at home.
Physician has ordered Coumadin 2.5 mg po on admission. No labwork on chart to
explain difference in Coumadin dosage. The physician would need
to be contacted
about this discrepancy.
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Express Scripts/Medco Prescription Plan Information For Drug Coverage Review, Prior Authorization Process and Personalized Medicine Information The endowed health plan offers faculty and staff members and their families a very comprehensive prescription drug program at relatively low costs to the consumer. Prescription drugs have become an important part of health plan coverage. The prescrib