Medication Reconciliation at Admission Checklist
Complete medication reconciliation within 24 hours of admission to ensure accurate medication history and prevent adverse drug events.
- Industry: Healthcare
- Frequency: Every patient admission
- Estimated Time: 15-30 minutes
- Role: Pharmacist/Nurse
- Total Items: 51
- Compliance: Joint Commission NPSG.03.06.01, CMS CoP, ISMP Guidelines
Medication Information Sources
Gather medication information from multiple sources
- Patient/family interview completed?
- Home medication list obtained?
- Community pharmacy contacted?
- Previous medical records reviewed?
- PCP office contacted if needed?
Medication Verification
Verify each medication
- All drug names verified (brand/generic)?
- All doses verified?
- All routes verified?
- All frequencies verified?
- Last dose date/time documented?
High-Risk Medications
Special attention to high-risk medications
- Anticoagulants reviewed and documented?
- Insulin regimen reviewed?
- Opioid medications reviewed?
- Immunosuppressants reviewed?
OTC & Supplements
Document non-prescription items
- OTC medications documented?
- Vitamins/supplements documented?
- Herbal products documented?
Allergies & Reactions
Document allergy information
- Drug allergies verified?
- Reaction types documented?
- NKDA confirmed if applicable?
Reconciliation Actions
Determine actions for each medication
- Medications to continue identified?
- Medications to hold identified?
- Medications to discontinue identified?
- New medications ordered?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
Environment of Care & Safety
Verify facility environment meets safety standards
- Fire exits clear and unobstructed?
- Emergency equipment functional and accessible?
- Spill kits available and stocked?
- Electrical cords and outlets in safe condition?
Documentation & Regulatory Compliance
Complete assessment documentation and ensure regulatory compliance
- All findings documented with evidence?
- Corrective actions assigned with timeline?
- Staff education provided on identified issues?
- Assessor Signature
- Additional Observations
Related Healthcare Checklists
- Medication Administration Safety Checklist
- Pediatric Weight-Based Medication Dosing Checklist
- Anticoagulation Therapy Monitoring Checklist
- Chemotherapy Administration Safety Checklist
- HIPAA Privacy Compliance Audit Checklist
- HIPAA Security Rule Audit Checklist
- CMS Emergency Preparedness Compliance Checklist
- Surgical Time-Out Verification Checklist
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Why Use This Medication Reconciliation at Admission Checklist?
This medication reconciliation at admission checklist helps healthcare teams maintain compliance and operational excellence. Designed for pharmacist/nurse professionals, this checklist covers 51 critical inspection points across 12 sections. Recommended frequency: every patient admission.
Ensures compliance with Joint Commission NPSG.03.06.01, CMS CoP, ISMP Guidelines. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Medication Reconciliation at Admission Checklist cover?
This checklist covers 51 inspection items across 12 sections: Medication Information Sources, Medication Verification, High-Risk Medications, OTC & Supplements, Allergies & Reactions, Reconciliation Actions, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management, Environment of Care & Safety, Documentation & Regulatory Compliance. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed every patient admission. Each completion takes approximately 15-30 minutes.
Who should use this Medication Reconciliation at Admission Checklist?
This checklist is designed for Pharmacist/Nurse professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.