Medication Reconciliation Audit
Audit medication reconciliation at each transition of care to catch discrepancies early, document changes clearly, and support safer admissions, transfers, and discharges.
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Built for: Healthcare · Hospitals · Pharmacy · Quality Assurance
What's inside this template
Audit Details
- Patient encounter type identified
- Audit date and time recorded
- Auditor name and role documented
- Source record reviewed
- Care transition stage clearly identified
Home Medication List Verification
- Home medication list obtained from a reliable source
- Medication name, dose, route, and frequency documented for each home medication
- Over-the-counter medications, supplements, and herbals reviewed
- Medication allergies and adverse reactions documented
- Last dose information captured when applicable
Discrepancy Identification and Resolution
- Medication discrepancies identified and documented
- Unintentional discrepancies were clarified with the patient, caregiver, or prescriber
- Intentional medication changes were clearly documented with rationale
- High-risk medications were reviewed for safety and duplication
- Resolved discrepancies were communicated to the care team
Admission and Transfer Medication Orders
- Admission or transfer medication orders match the reconciled home medication list where appropriate
- Held, discontinued, or substituted medications are documented with rationale
- PRN medications reviewed for appropriateness and duplication
- Medication orders were entered within required timeframe
Discharge Reconciliation and Patient Education
- Discharge medication list reconciled against inpatient medications
- New, changed, and discontinued medications clearly communicated
- Patient or caregiver received medication education
- Follow-up instructions and monitoring parameters provided
Common use cases
Frequently asked questions
When should this audit be used?
Use it at admission, transfer, and discharge when medication lists must be verified against the source record. It helps confirm what the patient was taking before the encounter and what should continue, change, or stop.
Who should complete the audit?
A nurse, pharmacist, or quality reviewer can complete it, depending on your workflow and policy. The template captures the auditor name, role, and review source so accountability is clear.
What medication details should be verified?
Document medication name, dose, route, frequency, and last dose when available. The template also prompts review of OTC products, supplements, herbals, allergies, and adverse reactions.
How does this template help reduce medication errors?
It separates intentional changes from unintentional discrepancies and requires a rationale for holds, substitutions, or discontinuations. That makes it easier to identify omissions, duplications, and unsafe overlaps before they reach the patient.
Can this be used for discharge education review?
Yes. The discharge section checks that new, changed, and discontinued medications are communicated clearly and that the patient or caregiver receives education, follow-up instructions, and monitoring guidance.
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