Emergency Department Medication Reconciliation Record
Patient Information
Patient Name
MRN / ID
Date of Birth
Date/Time of Admission
Attending Physician
Source of Medication Information
Current Medications
Medication Name
Dosage
Route
Frequency
Last Dose Taken
Comments
Allergies
Medications to be Continued / Discontinued / Changed in ED
Medication Name
Action (Continue/Discontinue/Change)
New Dose/Instructions
Reason/Comments
Additional Notes
Recorder Name
Date & Time of Reconciliation