Audit

Medication Reconciliation Audit Template

Interactive audit form and sampling plan to assess the accuracy, timeliness, and clinical significance of medication reconciliation at transitions of care, including root-cause prompts, scoring rubric, dashboard-ready fields, and recommended follow-up actions tied to governance.

Interactive Tool

Medication Reconciliation Audit

Purpose: Quickly capture whether medication reconciliation was completed, whether the medication list matches the best available sources, and whether discrepancies are clinically significant. Use this audit to identify system problems (workflows, EHR defaults, communication gaps) rather than blaming individuals; pair audits with the Med Reconciliation Playbook to close the loop.

Sampling guidance: Choose a statistically meaningful sample where possible. For ongoing monitoring consider weekly random sampling by ward/unit (e.g., 5–10 discharges or admissions per unit per week) and targeted sampling for high-risk populations (polypharmacy, older adults, opioid/anticoagulant users, transfers). For one-off investigations, use focused sampling (e.g., consecutive discharges after a process change).

Scoring rubric (suggested): Use number of discrepancies, clinical significance, and timeliness to generate a simple score. Example: Excellent = 0–1 discrepancy (no clinically significant findings); Good = 2–3 (low significance); Needs improvement = 4–6 or any moderate/high clinical significance; Poor = >6 or any potentially severe discrepancy. Adapt thresholds to local risk tolerance and patient mix.

How to use this form: Complete one form per audited patient encounter. Save submissions to build dashboards showing discrepancy rates by unit, by source, by discrepancy type, and by root cause category.

Enter the date you performed this audit. Use ISO format.
Name and role (e.g., Jane Perez, Pharmacy Technician).
Where the patient was cared for at time of transition.
Optional: enter unit name when 'Other' selected.
Were you auditing an admission, discharge, or another transition?
Why this case was selected.
Use local de-identified reference (e.g., MRN-last4 or audit ID). Avoid full PHI in shared reports.
Select the source you used as the reference for the reconciliation.
Enter total count of discrete discrepancies (omission, wrong dose, wrong frequency, duplication, etc.).
Select the types that apply to this encounter.
Describe the most clinically relevant discrepancies (e.g., 'Home warfarin omitted on admission, insulin dose listed incorrectly').
Rate the most significant discrepancy for this case. 0=None, 1=Low, 2=Moderate, 3=High, 4=Potentially severe.
1.0 10.0
Expected timeframe = within 24 hours of admission or prior to discharge/transfer per local policy.
Document any corrective action (medication restarted, dose corrected, patient counselled, prescriber notified).
Use these prompts to help identify system-level causes.
Select proposed actions; record assignments below.
Who should be assigned to complete the follow-up action(s)?
Optional: enter owner name or role.
Enter target date for completing follow-up actions.
Choose category that best matches your local scoring rubric.
Include contextual notes that help governance interpret this result.
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