Geriatric Medication Reconciliation Checklist
Patient Information
Name:
DOB:
Medical Record #:
Date:
Current Medication List
Medication Name
Dosage
Route
Frequency
Indication
Prescriber
Supplements/OTC/Herbals
Product
Dosage
Frequency
Indication
Allergies / Adverse Reactions
Substance
Reaction
Medication Changes
Medication
Change (Start/Stop/Modify)
Reason
Potential Issues
Reconciled By
Name:
Role:
Date: