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Medication reconciliation template

Australian documentation guide

A record of the sources checked, the medicine list, differences identified, decisions documented and items still unresolved. It keeps an unresolved discrepancy visible rather than treating every source list as an agreed current regimen.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Sources used

Identify the records and people consulted and, where established, their dates or currency. Examples include the person, a carer, medicine containers, a GP list or a discharge document. Name unavailable sources rather than implying that every source was checked.

Current medications

Record the established list and its evidence. Preserve name, strength, formulation, dose, route, frequency and status when known. Distinguish reported current use from an active order or recent dispensing. Do not calculate a missing dose or infer an indication from the medicine.

Allergies and adverse drug reactions

Record the substance, reported reaction, source and verification status. Retain a disputed or incomplete entry as such. “None known” is not interchangeable with “history not obtained”, and reconciliation does not by itself adjudicate a reaction.

Discrepancies identified

Describe the disagreement between specific sources: omission, additional item, dose, frequency, formulation or status difference. State what each source says. Distinguish an explained intentional change from an unresolved discrepancy; do not choose the most recent list automatically.

Actions and resolutions

Record the action actually taken, who authorised or confirmed it, when known, and the resulting status. “Clarified”, “communicated”, “order updated” and “awaiting prescriber review” are different events. A discussion or suggested change is not proof of a changed prescription.

Unresolved items

List each remaining uncertainty, the information still needed and the established follow-up owner or timing. Keep unresolved items separate from completed resolutions. If responsibility has not been agreed, state that rather than inventing an owner.

Common omissions

A discrepancy can disappear when two lists are merged. Source identity, intentional-versus-unexplained changes, authorisation and the unresolved-item handover need explicit entries.

Review before saving

Trace each recorded resolution back to its discrepancy and evidence. Check that the final list does not turn an unverified report into an order and that every unresolved matter remains visible to the next reviewer. This is a record scaffold, not a medicine-change recommendation.

Worked examples

Reconciling an old vitamin entry

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

SOURCES USED: Interview with the person, their current practice summary and a telephone check with their nominated community pharmacy.
CURRENT MEDICATIONS: Person reports no current regular medicines. Pharmacy confirms no current regular dispensing. The practice summary still lists a vitamin D product.
ALLERGIES & ADVERSE REACTIONS: Person reports no known medicine allergy or adverse reaction. That reported status agrees with the practice summary.
DISCREPANCIES IDENTIFIED: Practice summary lists vitamin D as current; the person states they stopped taking it six months ago. Pharmacy reports the last supply was more than six months ago.
ACTIONS & RESOLUTIONS: Pharmacist records the discrepancy and the person’s account. The entry is marked as reported ceased, with the source and date of this reconciliation recorded; prescriber confirmation is requested.
UNRESOLVED ITEMS: Prescriber confirmation of the old vitamin entry is pending. The practice pharmacist owns that check and will update the shared list after the response. No dose is inferred from the old entry.

A source discrepancy still awaiting verification

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

SOURCES USED: Person's account today and a medicine list dated last month.
CURRENT MEDICATIONS: The current regimen has not yet been established in this fictional extract.
ALLERGIES & ADVERSE REACTIONS: Person reports no known medicine allergies; other sources have not yet been checked.
DISCREPANCIES IDENTIFIED: Person reports one medicine has stopped; the dated list still includes it. Medicine name and directions are not stated in this extract.
ACTIONS & RESOLUTIONS: Pharmacist documents that the difference remains unverified and contacts the prescribing practice.
UNRESOLVED ITEMS: Reason and date of the reported stop remain unknown. Pharmacist will update the record after the practice responds.

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.