Collateral Materials for Medication Reconciliation
The following materials were created by Legacy Health's Medication Reconciliation Task Force. Legacy grants permission to other hospitals and healthcare systems to use the medication reconciliation process and collateral materials we have created, with credit to Legacy Health.
Physician/Staff Consent and Authorization for Institutional Review Board Approved Research(PDF)—Provides information to staff/physicians about the nature of the research study; signing the form indicates the person understands the study and agrees to participate in the project.
Patient/Family Consent and Authorization for Institutional Review Board Approved Research(PDF)—Provides information to the patient about the nature of the research study; signing the form indicates the patient understands the study and agrees to participate in the project.
Fax cover letter for pharmacies—Used to request the pharmacy's assistance with the collection of an accurate home medication list for one of their patients/clients
Fax cover letter for next provider—Used to send the patient's current list of medications to be taken upon discharge/release to the next provider of service and/or to the patient's primary care physician.
Script for focus groups—Use these scripts when conducting focus groups of physician/staff members and patient/family members to measure the success of your medication reconciliation process and the medication lists you have created, to allow you to make any necessary changes.
Data sheets to be completed by the unit and sent to Quality for tabulation:
Personal Medication Form—A form people can use to list all their current prescription and over-the-counter medications.
Medication Wallet Card—A smaller form people can carry with them that lists all their current prescription and over-the-counter medications.
For all disciplines
Interdisciplinary Duties for Medication Reconciliation (Word)—Explains the duties of the nursing staff, physicians and pharmacy in the medical reconciliation process.
RxPad Cheat Sheet—Abbreviated instructions for nursing, physicians, pharmacy, admitting and discharge about how to use RxPad for medication reconciliation.
Physician Instructions for RxPad Medication Entry and Faxing (PDF)—Step by step instructions for physicians on how to write prescriptions using RxPad and print them for the patient's chart or fax them to a pharmacy. Companion piece to Medication Reconciliation Instructions for Physicians.
Medication Reconciliation Instructions for Physicians (PDF)—Instructions for physicians about their responsibilities for reconciling medications at admit, transfer and discharge. Companion piece to Physician Instructions for RxPad Medication Entry and Faxing.
RxPad Cheat Sheet-Abbreviated instructions specifically for physicians about how to use RxPad for medication reconciliation.
Medication Reconciliation Training Packet for the Admitting Nurse—Complete explanation of the medication reconciliation process at Legacy Health, including entering the information into E-Chart and RxPad.
Nursing Medication Reconciliation Process Steps—Detailed checklist of the nurse's responsibility for medication reconciliation at admittance, transfer and discharge.
Pharmacist Self-Learning Module (PDF)—Explains the pharmacist's role in the medical reconciliation process.
For the ED
Medication reconciliation in emergency departments (PDF)—Main points of the reconciliation process specific to emergency departments.