# 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.

<!--
Guidance: How to use this template
- Start at admission. Reconciliation at transfer and discharge depends
  on an accurate admission list; the High 5s guide calls admission the
  foundation for the whole episode.
- Aim to complete the BPMH and pass discrepancies to the prescriber
  within 24 hours of the decision to admit, as the High 5s guide
  recommends; later reconciliation still helps the patient. National
  guidance may set its own timing: for example NICE NG5 (England, 2015)
  also uses a 24 hour window for acute admissions.
- Use at least two sources, one of which is a conversation with the
  patient or carer where possible. Record what the patient actually
  takes, which may differ from the label.
- Every difference between the BPMH and the orders must end as one of
  three types: intentional (documented), undocumented intentional
  (clarify and document) or unintentional (correct).
- Whoever completes the BPMH should be trained for the task; the High
  5s guide recommends pharmacy staff where available.
- Related templates: History and Physical
  (`healthcare/history-physical`), Discharge Summary
  (`healthcare/discharge-summary`), I-PASS Handover
  (`healthcare/ipass-handover`), Patient Safety Incident Report
  (`healthcare/patient-safety-incident-report`) for a discrepancy that
  reached the patient, PDSA Cycle (`healthcare/pdsa-cycle`) to improve
  the reconciliation rate.
-->

## Document control

<!-- Guidance: One record per transition. Link transfer and discharge records to the admission record by Document ID. -->

| 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

<!-- Guidance: Confirm allergies and intolerances with the patient, not only from the old record, and record the reaction. -->

| 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

<!-- Guidance: Tick every source used. Use at least two. Pitfall: copying an old discharge letter as the "history" without asking the patient. -->

| 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

<!-- Guidance: List every medicine the patient takes, including over-the-counter, herbal, inhaled, topical, eye drops, injections given elsewhere and recently stopped medicines. Record how the patient actually takes each one. -->

| # | 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

<!-- Guidance: Compare each BPMH line with the current orders and record a status. Then list every difference as a discrepancy in section 5. -->

| 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

<!-- Guidance: Classify each discrepancy with the three High 5s types. An unintentional discrepancy is a potential medication error: correct it and decide whether to report it as an incident. -->

| 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

<!-- Guidance: At transfer, compare the sending orders with the receiving orders. At discharge, compare the admission BPMH plus inpatient changes with the discharge list, and explain every change to the patient. -->

| 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

<!-- Guidance: Use the flow to agree roles locally: who takes the BPMH, who reconciles, who resolves. -->

The flow repeats at every transition; discharge closes the loop by
sending the reconciled list to the next care provider.

```mermaid
flowchart TD
    A["Decision to admit"] --> B["BPMH from two or more sources"]
    B --> C["Compare with orders"]
    C --> D{"Discrepancy?"}
    D -- "No" --> E["Record reconciled"]
    D -- "Yes" --> F{"Type"}
    F -- "Intentional" --> E
    F -- "Undocumented intentional" --> G["Prescriber documents reason"]
    F -- "Unintentional" --> H["Prescriber corrects, consider incident report"]
    G --> E
    H --> E
    E --> I["Transfer or discharge: reconcile again and send list"]
```

## References

<!-- Guidance: Name the national or local guidance your organisation follows and its date. -->

| 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.