Medication Reconciliation Record: [Patient identifier, transition]
Record of medication reconciliation at admission, internal transfer
and discharge: a best possible medication history (BPMH) from more
than one source, comparison with current orders, and documented
resolution of every discrepancy. The process and the three discrepancy
types follow the WHO High 5s Project (Action on Patient Safety)
Medication Reconciliation Implementation Guide, version 4, October
2014, which supports the "Assuring Medication Accuracy at Transitions
in Care" Standard Operating Protocol.
Replace every [bracketed] value and every row marked Example.
This is a documentation format, not medical advice; check the current
official guidance, follow local policy and prescribing rules, and use
clinical judgement. Use fictional data in examples.
Document control
| Field | Value |
|---|
| Document ID | [MR-YYYY-NNNN-ADM] |
| Patient | [Identifiers per facility policy] |
| Transition | [Admission / internal transfer / discharge] |
| Linked admission record | [MR-YYYY-NNNN-ADM, or this record] |
| Decision to admit | YYYY-MM-DD HH:MM |
| BPMH completed | YYYY-MM-DD HH:MM, by [Name, role] |
| Reconciled with orders | YYYY-MM-DD HH:MM, by [Name, role] |
| Version | [1.0] |
| Status | [BPMH in progress / Discrepancies open / Reconciled] |
| Owner | [@clinician] |
| Approvers/reviewers | [@prescriber], [@pharmacist] |
| Last updated | YYYY-MM-DD |
| Classification | [Confidential: patient record] |
Revision history
| Version | Date | Author | Change |
|---|
| 1.0 | YYYY-MM-DD | [Role] | BPMH and reconciliation recorded |
| 1.1 (Example) | YYYY-MM-DD | [Role] | Discrepancy D-02 resolved by prescriber |
1. Patient details and alerts
| Item | Detail |
|---|
| Age, weight, renal function | [Age, kg, latest eGFR or creatinine clearance and date] |
| Allergies and intolerances | [Substance, reaction, severity, source] / [No known allergies, confirmed with patient] |
| Pregnancy or breastfeeding | [Yes / no / not applicable] |
| Swallowing or administration needs | [Detail] |
| Who manages medicines at home | [Self / carer / compliance aid / care home] |
| Community pharmacy and usual prescriber | [Names, contact] |
2. Sources used
| Source | Used | Date and detail |
|---|
| Patient or carer interview | [ ] | [Detail] |
| Medicine containers or patient's own list | [ ] | [Detail] |
| Community pharmacy record | [ ] | [Detail] |
| Primary care or usual prescriber record | [ ] | [Detail] |
| Shared or national medication record, where available | [ ] | [System name] |
| Previous hospital or care home records | [ ] | [Detail] |
3. Best possible medication history
| # | Medicine | Dose | Route | Frequency | Last dose taken | Patient actually takes | Source(s) |
|---|
| 1 | [Name] | [Dose] | [Route] | [Frequency] | YYYY-MM-DD HH:MM | [As prescribed / differently: detail] | [Sources] |
| 1 (Example) | Apixaban | 5 mg | Oral | Twice daily | Day of admission 08:00 | As prescribed | Patient, community pharmacy |
| 2 (Example) | Ramipril | 5 mg | Oral | Once daily | Day before admission | As prescribed | Patient, GP record |
| 3 (Example) | Furosemide | 40 mg | Oral | Once daily | Two days before admission | Skips on days out | Patient |
| 4 (Example) | St John's wort (over the counter) | 1 tablet | Oral | Once daily | Day of admission | Self-started | Patient |
4. Reconciliation with orders
| BPMH # | Current order | Status |
|---|
| 1 (Example) | Apixaban 5 mg twice daily | Continued, matches |
| 2 (Example) | Not ordered | Discrepancy D-01 |
| 3 (Example) | Furosemide 40 mg once daily | Continued, adherence noted |
| 4 (Example) | Not ordered | Discrepancy D-02 |
| New (Example) | Clarithromycin 500 mg twice daily | Discrepancy D-03 (new medicine) |
5. Discrepancies and resolution
| Type | Meaning | Action |
|---|
| Intentional | Prescriber chose to add, change or stop a medicine and documented why | Record only |
| Undocumented intentional | The choice was deliberate but the reason was not documented | Ask the prescriber to document |
| Unintentional | A medicine was changed, added or omitted by mistake (omission or commission) | Prescriber corrects, consider incident report |
| ID | Medicine | Type | Discussed with | Resolution | Time resolved |
|---|
| D-01 (Example) | Ramipril held | Undocumented intentional | Admitting doctor | Held for acute kidney injury risk, reason now documented | HH:MM |
| D-02 (Example) | St John's wort omitted | Intentional after review | Admitting doctor, pharmacist | Stopped: interaction risk with apixaban; reason documented, patient informed | HH:MM |
| D-03 (Example) | Clarithromycin started | Intentional | Pharmacist | New for pneumonia; interaction with apixaban flagged, prescriber changed to an alternative antibiotic | HH:MM |
Summary: [N] medicines in BPMH, [N] discrepancies, [N] unintentional,
[N] still open. Example: 4 medicines, 3 discrepancies, 0
unintentional, 0 open.
6. Transfer and discharge
| Medicine | Before admission | At discharge | Change and reason | Patient told |
|---|
| Ramipril (Example) | 5 mg once daily | Restart 2.5 mg once daily | Restarted at a lower dose once kidney function recovered; review in two weeks | Yes |
| St John's wort (Example) | Once daily | Stopped | Interaction with apixaban | Yes, written note given |
- Updated list sent to: [Usual prescriber, community pharmacy, care home]
- Discharge summary reference: [Document ID], see
healthcare/discharge-summary
7. Process flow
The flow repeats at every transition; discharge closes the loop by
sending the reconciled list to the next care provider.
References
| Reference | Status | Use |
|---|
| WHO High 5s Project (Action on Patient Safety). Medication Reconciliation Implementation Guide, Assuring Medication Accuracy at Transitions in Care, version 4 (October 2014), https://cdn.who.int/media/docs/default-source/patient-safety/high5s/h5s-guide.pdf | Checked 2026-10-30 (PDF read) | BPMH sources, 24 hour target, three discrepancy types, proactive and retroactive models |
| NICE NG5, Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015), https://www.nice.org.uk/guidance/ng5 | Not re-checked (site blocked automated access) | England example of timing and roles |
| The Joint Commission, hospital accreditation requirements on medication reconciliation (formerly NPSG.03.06.01; from 2026-01-01 the hospital National Patient Safety Goals chapter was reorganised into National Performance Goals, as reported by secondary sources), https://www.jointcommission.org/ | Not re-checked on the official site (blocked automated access); check the current goal number in the manual | US accreditation example |
Standard and licence note
Based on the WHO High 5s Medication Reconciliation Implementation Guide
(version 4, October 2014) and its Standard Operating Protocol, with England
(NICE NG5) and US (The Joint Commission) examples named for context.
This template is original text written for this collection and does
not reproduce the WHO forms. All names and clinical details in examples
are fictional. This is a documentation format, not medical advice;
check the current official guidance, local prescribing policy and a
qualified professional. Template licence: MIT.