Medication Reconciliation Audit

Audit medication reconciliation accuracy at admission, transfer, and discharge to verify home medication lists, identify discrepancies, and support safe transitions of care.

Audit Details

• Care transition audited
  Select the transition point being audited.
• Audit date and time
  Record when the audit was completed.
• Unit or care area
  Enter the unit, clinic, or care area where the reconciliation was reviewed.
• Auditor name
  Enter the name and role of the person completing the audit.

Home Medication List Verification

• Home medication list obtained from a reliable source
  Verify whether the home medication list was collected from the patient, caregiver, pharmacy, prior records, or another reliable source.
• Medication name, dose, route, and frequency documented for each home medication
  Check that each listed home medication includes complete identifying details.
• Allergies and adverse reactions documented and visible
  Confirm allergies and prior adverse drug reactions are documented in the record and available to the care team.
• Last dose information documented for high-risk or time-sensitive medications
  Verify last dose timing is documented when clinically relevant, such as for anticoagulants, insulin, opioids, anticonvulsants, or inhalers.
• Medication list reviewed with patient or caregiver when feasible
  Confirm the list was validated with the patient, caregiver, or another appropriate source when possible.

Discrepancy Identification and Resolution

• Unintentional discrepancies identified and documented
  Check whether omissions, duplications, dose changes, route changes, frequency changes, or drug interactions were identified and documented.
• Discrepancies resolved by prescriber or authorized clinician
  Verify that unresolved differences were clarified and resolved by an authorized clinician.
• Reason for medication changes documented
  Confirm the chart includes a reason for additions, discontinuations, substitutions, or dose adjustments.
• High-alert medications independently verified
  Confirm high-alert medications were verified using an independent double-check or equivalent safety process when applicable.

Admission and Transfer Medication Orders

• Current medication orders match the reconciled list
  Verify that active orders align with the reconciled medication list for the current level of care.
• Medications intentionally held, substituted, or discontinued are clearly documented
  Confirm the record shows which medications were intentionally not continued and why.
• Transfer handoff includes updated medication list
  Verify the receiving team has access to the updated medication list and any pending clarification items.
• Medication reconciliation completed within facility policy timeframe
  Enter the elapsed time from admission or transfer to completion of reconciliation.

Discharge Reconciliation and Patient Education

• Discharge medication list matches final reconciled orders
  Verify the discharge medication list reflects all final medication changes and intended continuations.
• Patient or caregiver received medication education
  Confirm education was provided on new, changed, and discontinued medications, including purpose and key precautions.
• Follow-up instructions for medication questions or concerns documented
  Verify the discharge record includes who to contact for medication-related questions and when to seek help.
• Teach-back or understanding verified when applicable
  Confirm the patient or caregiver demonstrated understanding of the discharge medication plan when feasible.