Gold Standard Medication Admission Comparison Discharge Comparison Name: Note Differences: Note Differences: (select all that (select all that Dose/Route/ Dose Omission Dose Omission Frequency: Frequency Route Frequency Route Additional med Substitution Additional med Substitution Drug Class: Duplication Formulation Duplication Formulation PRN Duration Other: Duration Other: OTC Reason: Reason: Pt Adherence: Unintentional (History Unintentional (History Systematically Completely or Reconciliation Error) or Reconciliation Error) Intentional (Clinical Intentional (Clinical Sporadically Adherent Reason) Reason) Were there any unintentional Were there any unintentional Comments: discrepancies between the gold standard discrepancies between the gold standard and the admission order? and the discharge order? All Sources Used: Yes Yes Patient No No Patient’s family/Caregiver Pill Bottles Patient’s Own Med List Outpatient EMR Outpatient Provider(s) Transfer Records If count as 1 If count as 1 “yes,” “yes,” Past DC Summary Pharmacy(s) Pharmacy Database Other: *Completely non-adherent means the patient has not been taking the medication for at least 30 days. If completely non-adherent, do not include. Move on to the next Gold Standard Medication.
Gold Standard Medication Admission Comparison Discharge Comparison Name: Dose/Route/ Frequency: Drug Class: PRN OTC Pt Adherence: Completely Sporadically Comments: All Sources Used: Patient Pill Bottles Outpatient EMR Transfer Records Pharmacy(s) Other: Systematically Adherent Patient’s family/Caregiver Patient’s Own Med List Outpatient Provider(s) Past DC Summary Pharmacy Database Note Differences: (select all that Dose Frequency Additional med Duplication Duration Reason: Unintentional (History or Reconciliation Error) Intentional (Clinical Reason) Omission Route Substitution Formulation Other: Note Differences: (select all that Dose Frequency Additional med Duplication Duration Reason: Unintentional (History or Reconciliation Error) Intentional (Clinical Reason) Omission Route Substitution Formulation Other: Were there any unintentional discrepancies between the gold standard and the admission order? Yes No If “yes,” count as 1 Were there any unintentional discrepancies between the gold standard and the discharge order? Yes No If “yes,” count as 1 *Completely non-adherent means the patient has not been taking the medication for at least 30 days. If completely non-adherent, do not include. Move on to the next Gold Standard Medication.