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Medication reconciliation note template

Designed for moments when the medication list must be right—admission, discharge, post-hospital follow-up, or multi-prescriber chaos. Capture sources, discrepancies, and what you changed.

Template content

Copy or download, then paste into Wavo under My Templates.

Medication Reconciliation

Context
- Setting (admission, discharge, ambulatory transition, pre-op) and date/time.
- Who participated (patient, caregiver, pharmacist, nurse) and language/interpreter if used.

Sources Reviewed
- Patient/caregiver report, medication bottles, pharmacy fill history, prior EHR list, discharge/transfer medication list, and outside records as available.
- Best-possible medication history confidence (high/moderate/low) and gaps.

Home / Prior-to-Visit Medication List
- Medication, dose, route, frequency, indication if known, and adherence notes.
- OTCs, supplements, and as-needed medications.

Discrepancies Identified
- Omissions, duplications, dose/frequency mismatches, and unintentional continuations/discontinuations.
- Intentional changes already made by clinicians (document as intentional).

Actions Taken
- Medications continued, held, stopped, or started with rationale.
- Allergy/interaction issues addressed.
- Patient education on the updated list; teach-back if performed.

Updated Current Medication List
- Final reconciled list reflecting today’s decisions.
- Pending confirmations (e.g., awaiting pharmacy callback) clearly marked.

Follow-Up
- Who will resolve remaining uncertainties and by when.
- Discharge or ambulatory follow-up med-rec needs.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Forces source documentation (patient, bottles, pharmacy, discharge list).
  • Surfaces discrepancies and intentional vs unintentional changes.
  • Works across inpatient and ambulatory transition workflows.
  • Leaves a clean “current list” clinicians can trust at the next handoff.
  • 1Hospital admission and discharge med reconciliation
  • 2Post-hospital ambulatory follow-up
  • 3Complex polypharmacy clinic visits

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Context
Ambulatory post-hospital visit day 5 after CHF admission. Patient and daughter present; English.

Sources
Hospital discharge med list, patient bottles brought today, outpatient EHR list, pharmacy fill history. Confidence: high.

Discrepancies
Home list still showed furosemide 20 mg daily; discharge increased to 40 mg BID. Outpatient list duplicated metoprolol succinate and tartrate. Spironolactone on discharge list; patient unsure if started.

Actions
Stopped metoprolol tartrate duplicate; continue metoprolol succinate 50 mg daily. Continue furosemide 40 mg BID as discharged. Confirmed spironolactone 25 mg daily started; bottle filled. Reinforced low-sodium diet and daily weights.

Current List
Carvedilol not on regimen—patient on metoprolol succinate 50 mg daily; sacubitril/valsartan 49/51 BID; spironolactone 25 mg daily; furosemide 40 mg BID; atorvastatin 40 mg QHS; apixaban 5 mg BID. NKDA.

Follow-Up
BMP in 3 days (K, Cr after diuretic increase); message weight gain >3 lb in 1 day. Pharmacy notified of cleaned list.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.