UR. Number .............................................................................

Surname .............................................................................

Given Name(s) .............................................................................

AFFIX PATIENT LABEL HERE

Section 1 MEDICATION HISTORY ON ADMISSION

This form is completed by a pharmacist when documenting medication taken prior to admission. Medication changes made during the hospital stay should be
documented in the patient's medical record and discharge prescription and communicated in the discharge summary. Medication taken prior to admission Reconciled
Reconciling medications on admission refers to the process of comparing the medication history and the medication prescribed on admission with the treatment plan. (includes prescription, non-prescription & complementary medication) Required on Comments
on
DC? (ceased, withhold, dose
admission?
Social history: ............................................................................ Preferred language: .......................................... Interpreter required n Name, Form & Strength Dose, Route & Frequency (Y or N) change)
(✗ or ✓)
Medication usually administered by: Patient's own medication on ward: Yes n No n
Patient n Carer n RCF* n Location of patient's own medication:
Other (details): n ....................................................................... Bedside locker n Ward fridge n DA safe n
Medication administration device filled by:
Current medication aid: Yes n No n Patient n Carer n Community pharmacy n
(If yes, specify):............................................................................ Medication non-adherence identified: Yes n No n

Community Pharmacy: ............................................................ Tel: .................................................... Fax: .............................................

General Practitioner: ................................................................ Tel: .................................................... Fax: .............................................

Adverse Drug Reactions Nil known n / Unknown n (tick appropriate box or complete details of drug, reaction and data source)

Medication taken prior to admission Reconciled

(includes prescription, non-prescription & complementary medication) Required on
on Comments
DC? Comments:
admission? (ceased, withhold, dose change)
Name, Form & Strength Dose, Route & Frequency (Y or N)
(✗ or ✓) ....................................................................................................................................................................................................................................

N ....................................................................................................................................................................................................................................

I O ....................................................................................................................................................................................................................................

AT ....................................................................................................................................................................................................................................

R ....................................................................................................................................................................................................................................

ST
....................................................................................................................................................................................................................................

N I ....................................................................................................................................................................................................................................

I ....................................................................................................................................................................................................................................

D M ....................................................................................................................................................................................................................................

A ....................................................................................................................................................................................................................................

R
....................................................................................................................................................................................................................................

FO
....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

OT ....................................................................................................................................................................................................................................

N
....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................
Source of Information/Confirmation
....................................................................................................................................................................................................................................
Patient n Community Pharmacy n General Practitioner n Residential Care Facility* n
Carer n Own medication n Other (details): n .......................................................................................... ....................................................................................................................................................................................................................................

Pharmacist Name: .................................................... Signature: ..................................................... Pager:..................... Date:...................... Pharmacist Name: .................................................... Signature: ..................................................... Pager:..................... Date:.....................
Section 2 MEDICATION RISK ASSESSMENT

Please indicate with a tick ( ✓ ) Yes

Lives alone
Cognitive impairment
Taking multiple medications (> 4)
Medication/dose changes during admission
History of non-compliance

N
> 65 years and on medication that may increase falls risk
Taking a medicine requiring dosage adjustment

O
Unable to read medication labels
Taking cardiovascular or diabetes medication

I
Renal or hepatic impairment

AT
Adverse drug reactions
Non-English speaking
Other identified risk:

TR
................................................................................................................................................................................................................................

MEDICATION DISCHARGE PLAN

IS
Hospital outreach medication review recommended: n

MEDICATION HISTORY ON ADMISSION

Referred by: ................................................................ Signature: ...................................................... Pager: ..................... Date: .................
IN

Medication list required: Yes n No n

M

Medication administration aid recommended: Yes n No n

(If Yes, specify requirements).........................................................................................................................................................

AD

.......................................................................................................................................................................................................

Patient medicines information: (CMI, warfarin booklet, etc.)

R

Name of medicine and date provided: ..........................................................................................................................................

FO

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

Other special instructions for discharge: ....................................................................................................................................

T

.......................................................................................................................................................................................................
O
N

MEDICATION LIAISON AND FOLLOW-UP

Discharge medication counselling provided n

Discharge medication profile provided to: Community Pharmacy n Residential Care Facility n

Other (details): n ..............................................................................................................................................................................................

Pharmacist Name: .................................................... Signature: ..................................................... Pager:..................... Date:.................

Consented to hospital outreach medication review: Yes n No n

Consented by: ........................................................... Signature: ..................................................... Pager:..................... Date:.................

M79.9