XXXXXXX
Patient Name患者姓名: Sex性别:
Birth Date出生日期: Medical Record No病案号:
Medication Reconciliation at Admission (For Pharmacy)
Attending Physician: ___________________ Ward: ______ Admitted_____/____/____
(主治医师) (病房) (住院时间): Admission diagnoses(入院诊断): Past Medical History(病史):
1._________________________________________ 1.________________________________________ 2._________________________________________ 2.________________________________________
Allergies: ___________________
? Check here if patient is not currently on any medication.
Home Medications
Information source: ?Patient ?Family ?Other, specify___________________ Prescription Dosage Route Frequency Own Pharmacist Notes Medications/OTC/Vitamins /Signature (剂量) (途径) (次数) medication Brought-In (药品名称) Yes or No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Recommendation by pharmacist:
Pharmacist Signature (药师签名):_______________ Date(日期): ___ _/__ _ _/__ _ YY (年) MM(月) DD(日)
Recommendation accepted? Yes ?
Physician’s Signature (医生签名):______________Date(日期):＿＿／＿＿／＿＿ＹＹ（年）ＭＭ（月）ＤＤ（日）
No ?, please state reason_____________________________________________
Physician Decision: Continue? Circle one Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Office use only Last revised: XXXX.6.12 XXX-IPD-0004-E-FO-Draft
医院药物重整记录表
