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LittleMeds Safety

Version 1.0 | Audit date: ____________________

Pediatric Medication Reconciliation and Transition Audit

Professional notice: This audit must be used with the organization's approved medication-reconciliation policy, formulary, transition-of-care procedures, and documentation standards. It does not replace clinical judgment, patient-specific reconciliation, or institutional policy.

Audit Information

Facility or organization
Department or unit
Auditor
Audit date
Transition type
Population or care area
Policy or procedure reviewed
Policy version or revision date
Audit period
Number of records reviewed
Previous audit date
Notes

Transition Type Selection

Select the transition type being audited. Print the matching appendix module pages as needed.

Shared Core Blank Audit Form

Complete the shared core domains below for every transition type. Conditional domains and transition-specific modules are provided in the appendices so users may print only the pages needed for the selected transition type.

Governance and Accountability

Criterion Compliant Deficient N/A
A current medication-reconciliation policy defines required transition points Compliant Deficient N/A
Roles and responsibilities are clearly assigned Compliant Deficient N/A
Accountability for obtaining the medication history is defined Compliant Deficient N/A
Accountability for resolving discrepancies is defined Compliant Deficient N/A
Reconciliation timeframes are established Compliant Deficient N/A
Escalation pathways exist for unresolved discrepancies Compliant Deficient N/A
Pharmacy involvement is defined for high-risk situations Compliant Deficient N/A
The process includes inpatient, ambulatory, and external medication sources Compliant Deficient N/A
Staff receive training on the reconciliation process Compliant Deficient N/A
Compliance and effectiveness are reviewed on a defined schedule Compliant Deficient N/A
Notes:

Medication History and Source Verification

Criterion Compliant Deficient N/A
A structured medication-history process is used Compliant Deficient N/A
More than one reliable information source is used when available Compliant Deficient N/A
The child’s caregiver is involved when appropriate Compliant Deficient N/A
Prescription medications are included Compliant Deficient N/A
Nonprescription medications are included Compliant Deficient N/A
Vitamins, supplements, and herbal products are included Compliant Deficient N/A
As-needed medications are included Compliant Deficient N/A
Medication allergies and reaction details are verified Compliant Deficient N/A
Actual medication use is distinguished from the prescribed regimen Compliant Deficient N/A
Community pharmacy or external prescriber information is used when needed Compliant Deficient N/A
Uncertain information is clearly identified for follow-up Compliant Deficient N/A
Notes:

Medication-List Accuracy

Criterion Compliant Deficient N/A
Medication name is accurately documented Compliant Deficient N/A
Formulation is accurately documented Compliant Deficient N/A
Concentration is documented for liquid medications Compliant Deficient N/A
Strength is accurately documented Compliant Deficient N/A
Dose is accurately documented Compliant Deficient N/A
Dose units are clear Compliant Deficient N/A
Route is documented Compliant Deficient N/A
Frequency is documented Compliant Deficient N/A
Administration instructions are clear Compliant Deficient N/A
Scheduled and as-needed medications are differentiated Compliant Deficient N/A
Duplicate entries are identified Compliant Deficient N/A
Inactive medications are removed or clearly discontinued Compliant Deficient N/A
Brand and generic duplication is addressed Compliant Deficient N/A
Compounded products include sufficient formulation details Compliant Deficient N/A
Home medication devices are identified when relevant Compliant Deficient N/A
Notes:

Discrepancy Identification and Resolution

Criterion Compliant Deficient N/A
The current medication list is compared with transition orders Compliant Deficient N/A
Omitted medications are identified Compliant Deficient N/A
Unintended additions are identified Compliant Deficient N/A
Dose discrepancies are identified Compliant Deficient N/A
Concentration discrepancies are identified Compliant Deficient N/A
Route discrepancies are identified Compliant Deficient N/A
Frequency discrepancies are identified Compliant Deficient N/A
Duplicate therapy is identified Compliant Deficient N/A
Therapeutic substitutions are clearly documented Compliant Deficient N/A
Formulary substitutions are communicated Compliant Deficient N/A
Intentional medication changes include a documented rationale Compliant Deficient N/A
Unintentional discrepancies are resolved before transition completion Compliant Deficient N/A
Clinically urgent discrepancies are escalated immediately Compliant Deficient N/A
The final reconciled list reflects resolved decisions Compliant Deficient N/A
Resolution is communicated to relevant clinicians Compliant Deficient N/A
Notes:

Pediatric Dosing and Formulation Safety

Criterion Compliant Deficient N/A
Current weight in kilograms is available when needed for dosing Compliant Deficient N/A
The source and date of the dosing weight are identifiable Compliant Deficient N/A
Pounds are not used as the primary dosing unit Compliant Deficient N/A
Weight-based doses are recalculated when clinically appropriate Compliant Deficient N/A
Maximum doses are considered Compliant Deficient N/A
Age, gestational age, or developmental factors are considered when relevant Compliant Deficient N/A
Renal and hepatic function are considered where applicable Compliant Deficient N/A
Liquid medication concentration is explicitly verified Compliant Deficient N/A
Dose instructions include both medication amount and measurable volume when appropriate Compliant Deficient N/A
Appropriate oral dosing devices are supplied or recommended Compliant Deficient N/A
Tablet splitting or manipulation is assessed for feasibility and safety Compliant Deficient N/A
Compounded formulation availability is confirmed Compliant Deficient N/A
Pediatric and adult formulations are clearly differentiated Compliant Deficient N/A
Changes caused by growth or weight change are evaluated when relevant Compliant Deficient N/A
Notes:

High-Risk Patient and Medication Safeguards

Criterion Compliant Deficient N/A
High-risk patients are identified using defined criteria Compliant Deficient N/A
Children with medical complexity receive enhanced review Compliant Deficient N/A
Patients with polypharmacy receive enhanced review Compliant Deficient N/A
Patients using multiple pharmacies or prescribers receive enhanced review Compliant Deficient N/A
High-alert medications receive additional verification Compliant Deficient N/A
Anticoagulants receive transition-specific review Compliant Deficient N/A
Insulin receives transition-specific review Compliant Deficient N/A
Opioids and sedatives receive transition-specific review Compliant Deficient N/A
Chemotherapy or immunosuppressants receive specialized review Compliant Deficient N/A
Antiseizure medications receive continuity review Compliant Deficient N/A
Parenteral nutrition and infusion therapies receive specialized review Compliant Deficient N/A
Controlled-substance prescriptions are reconciled carefully Compliant Deficient N/A
Medication-device dependence is addressed Compliant Deficient N/A
Social, language, and health-literacy risks are considered Compliant Deficient N/A
Pharmacy or specialist review occurs when required by policy Compliant Deficient N/A
Notes:

Follow-Up and Continuous Improvement

Criterion Compliant Deficient N/A
Medication-access failures are tracked Compliant Deficient N/A
Reconciliation discrepancies are measured Compliant Deficient N/A
Errors and near misses are reviewed Compliant Deficient N/A
Discrepancy types are categorized Compliant Deficient N/A
Preventable readmissions or return visits involving medications are reviewed Compliant Deficient N/A
Caregiver feedback is considered Compliant Deficient N/A
Audit results are reported to relevant leadership Compliant Deficient N/A
Improvement actions are evaluated for effectiveness Compliant Deficient N/A
Policies are updated after significant process changes Compliant Deficient N/A
Reconciliation performance is reassessed periodically Compliant Deficient N/A
Notes:

Blank Audit Summary

Total applicable criteria
Compliant
Deficient
Not applicable
Readiness percentage
Readiness classification
Key findings
Recommended process actions
Auditor signature and date
Leadership reviewer signature and date

Scoring Formula

Readiness percentage = Compliant ÷ (Compliant + Deficient) × 100

Suggested Classifications

  • 95-100%: Process safeguards well established
  • 85-94%: Improvement opportunities identified
  • Below 85%: Priority process review recommended

These are suggested quality-improvement indicators and may be modified by institutional policy.

Appendix: Conditional Domains

Use the conditional domain set that matches the selected transition. These domains are not intended to appear for every audit.

Admission

Best Possible Medication History

Criterion Compliant Deficient N/A
Recently discontinued or completed therapies are clarified Compliant Deficient N/A
Last dose timing is obtained when clinically relevant Compliant Deficient N/A
Medication indication is documented when useful Compliant Deficient N/A
Medication history is initiated within the required timeframe Compliant Deficient N/A
External records are reviewed when needed Compliant Deficient N/A
Caregiver-provided medication information is preserved Compliant Deficient N/A
Notes:

Admission Order Comparison

Criterion Compliant Deficient N/A
Pre-admission medications are compared with admission orders Compliant Deficient N/A
Continue, hold, modify, or discontinue decisions are documented Compliant Deficient N/A
Home medications are reconciled before inpatient orders are finalized Compliant Deficient N/A
Temporary emergency orders are reviewed Compliant Deficient N/A
Unresolved discrepancies are escalated before routine care proceeds Compliant Deficient N/A
Notes:

Last-Dose and Time-Critical Medication Review

Criterion Compliant Deficient N/A
Time-sensitive medications are prioritized Compliant Deficient N/A
Last-dose timing is verified when important Compliant Deficient N/A
Time-critical home medications are addressed Compliant Deficient N/A
Last administration times are communicated Compliant Deficient N/A
Home medication supply brought to the facility is secured and documented Compliant Deficient N/A
Notes:

Internal Transfer

Internal Handoff Communication

Criterion Compliant Deficient N/A
The reconciled medication list is available to the receiving team Compliant Deficient N/A
Recent medication changes are clearly communicated Compliant Deficient N/A
Held medications are identified Compliant Deficient N/A
Discontinued medications are identified Compliant Deficient N/A
Time of last dose is communicated when clinically relevant Compliant Deficient N/A
Time of next dose is communicated when clinically relevant Compliant Deficient N/A
High-alert medications are highlighted Compliant Deficient N/A
Pending medication-related laboratory results are communicated Compliant Deficient N/A
Home medications brought into the facility are accounted for Compliant Deficient N/A
Medication devices and pumps are addressed Compliant Deficient N/A
Unresolved medication questions are explicitly handed off Compliant Deficient N/A
Notes:

Infusion and Active-Order Continuity

Criterion Compliant Deficient N/A
Active medications are reviewed before transfer Compliant Deficient N/A
Unit-specific order discontinuation is controlled Compliant Deficient N/A
Infusions are reconciled during transfer Compliant Deficient N/A
Medication administration record continuity is verified Compliant Deficient N/A
Continuous infusions include current dose and concentration Compliant Deficient N/A
Transfer orders reflect the intended regimen Compliant Deficient N/A
Notes:

Monitoring Continuity

Criterion Compliant Deficient N/A
Monitoring requirements accompany the handoff Compliant Deficient N/A
Held and delayed doses are communicated Compliant Deficient N/A
Receiving-unit formulary or storage differences are addressed Compliant Deficient N/A
High-alert medication monitoring continues without interruption Compliant Deficient N/A
Titrated medications include current settings and parameters Compliant Deficient N/A
Notes:

Interfacility Transfer

Transfer Documentation

Criterion Compliant Deficient N/A
A complete medication administration record accompanies the patient Compliant Deficient N/A
Current medication orders are transmitted Compliant Deficient N/A
Last-dose times are documented Compliant Deficient N/A
Medications sent with the patient are inventoried Compliant Deficient N/A
Notes:

Medication Supply During Transport

Criterion Compliant Deficient N/A
Medication supply during transfer is ensured Compliant Deficient N/A
Transport medication responsibilities are defined Compliant Deficient N/A
Essential medications are available before transition when required Compliant Deficient N/A
Appropriate administration devices are available Compliant Deficient N/A
Notes:

Receiving-Facility Communication

Criterion Compliant Deficient N/A
The receiving facility receives the reconciled medication list Compliant Deficient N/A
Unresolved medication issues are communicated directly Compliant Deficient N/A
Contact information is available for questions Compliant Deficient N/A
Direct clinician-to-clinician communication occurs for high-risk therapy Compliant Deficient N/A
Notes:

Formulary and Device Continuity

Criterion Compliant Deficient N/A
Receiving-facility formulary differences are anticipated Compliant Deficient N/A
Formulary substitutions are anticipated Compliant Deficient N/A
Infusion concentrations and rates are communicated Compliant Deficient N/A
Medication administration devices accompany the patient when necessary Compliant Deficient N/A
Notes:

Discharge Home

Discharge Medication Reconciliation

Criterion Compliant Deficient N/A
Admission medications are compared with discharge medications Compliant Deficient N/A
Inpatient-only medications are discontinued where appropriate Compliant Deficient N/A
Home medications to resume are clearly identified Compliant Deficient N/A
Medications to stop are clearly identified Compliant Deficient N/A
New medications are clearly identified Compliant Deficient N/A
Changed medications specify what changed Compliant Deficient N/A
Duplicate therapies are removed Compliant Deficient N/A
Temporary medications include duration or stop instructions Compliant Deficient N/A
Tapering schedules are clearly documented Compliant Deficient N/A
As-needed indications are understandable Compliant Deficient N/A
The discharge medication list matches prescriptions Compliant Deficient N/A
The discharge summary matches the final medication list Compliant Deficient N/A
Specialist recommendations are incorporated Compliant Deficient N/A
Stopped medications are removed from caregiver instructions Compliant Deficient N/A
Final home regimen is clearly identified Compliant Deficient N/A
Notes:

Caregiver Education and Teach-Back

Criterion Compliant Deficient N/A
Education is provided to the appropriate caregiver Compliant Deficient N/A
An interpreter is used when required Compliant Deficient N/A
Written instructions use understandable language Compliant Deficient N/A
Medication purpose is explained Compliant Deficient N/A
Dose and schedule are explained Compliant Deficient N/A
Medication changes are explicitly reviewed Compliant Deficient N/A
Stopped medications are explicitly reviewed Compliant Deficient N/A
Liquid concentration and measured volume are explained Compliant Deficient N/A
The correct measuring device is demonstrated Compliant Deficient N/A
Caregiver teach-back is used Compliant Deficient N/A
Caregiver demonstration is used when appropriate Compliant Deficient N/A
Important adverse effects are reviewed Compliant Deficient N/A
Missed-dose instructions are available when appropriate Compliant Deficient N/A
Storage requirements are explained Compliant Deficient N/A
Emergency and escalation instructions are provided Compliant Deficient N/A
Caregiver questions are addressed before transition completion Compliant Deficient N/A
Notes:

Prescription and Medication Access

Criterion Compliant Deficient N/A
Prescriptions match the reconciled medication list Compliant Deficient N/A
Prescriptions include the intended formulation Compliant Deficient N/A
Prescriptions include the intended concentration Compliant Deficient N/A
Prescriptions contain clear pediatric directions Compliant Deficient N/A
Required quantity reflects the planned duration Compliant Deficient N/A
Insurance or authorization barriers are identified Compliant Deficient N/A
Pharmacy availability is confirmed for uncommon formulations Compliant Deficient N/A
Compounded medication access is confirmed Compliant Deficient N/A
Refrigeration or storage needs are addressed Compliant Deficient N/A
Weekend and after-hours access barriers are considered Compliant Deficient N/A
A plan exists when the preferred product is unavailable Compliant Deficient N/A
Caregivers know where prescriptions were sent Compliant Deficient N/A
Financial barriers are escalated when identified Compliant Deficient N/A
Prescription access is confirmed Compliant Deficient N/A
Medication devices are supplied Compliant Deficient N/A
Home supplies and remaining medications are reconciled Compliant Deficient N/A
Notes:

Communication With Outpatient Clinicians

Criterion Compliant Deficient N/A
The reconciled medication list is sent to the next care setting Compliant Deficient N/A
Medication changes are highlighted Compliant Deficient N/A
Reasons for important changes are communicated Compliant Deficient N/A
High-alert medications are identified Compliant Deficient N/A
Monitoring requirements are communicated Compliant Deficient N/A
Required laboratory follow-up is communicated Compliant Deficient N/A
Pending medication-related results are communicated Compliant Deficient N/A
Duration and stop dates are communicated Compliant Deficient N/A
Tapering plans are communicated Compliant Deficient N/A
Administration-device requirements are communicated Compliant Deficient N/A
Compounded formulations are clearly described Compliant Deficient N/A
Follow-up prescriber responsibility is identified Compliant Deficient N/A
Communication occurs within the organization’s required timeframe Compliant Deficient N/A
Contact instructions are provided for medication questions Compliant Deficient N/A
Notes:

Follow-Up and Monitoring

Criterion Compliant Deficient N/A
Medication-related follow-up needs are documented Compliant Deficient N/A
Follow-up appointments are communicated Compliant Deficient N/A
Laboratory monitoring is scheduled or assigned Compliant Deficient N/A
A responsible clinician is identified for ongoing medication management Compliant Deficient N/A
Post-transition contact is used for selected high-risk patients Compliant Deficient N/A
Pending test results that may affect medication therapy are documented Compliant Deficient N/A
Follow-up monitoring requirements are documented Compliant Deficient N/A
Follow-up monitoring is arranged Compliant Deficient N/A
Notes:

Discharge to Another Facility

Receiving-Facility Medication Orders

Criterion Compliant Deficient N/A
The receiving facility receives the reconciled medication list Compliant Deficient N/A
Prescriptions or medication orders meet receiving-facility requirements Compliant Deficient N/A
Controlled-medication documentation is complete Compliant Deficient N/A
Current medication orders are transmitted Compliant Deficient N/A
Notes:

Medication Supply and Transport

Criterion Compliant Deficient N/A
Medication supply during transfer is ensured Compliant Deficient N/A
Medications sent with the patient are inventoried Compliant Deficient N/A
Transport medication responsibilities are defined Compliant Deficient N/A
Essential medications are available before transition when required Compliant Deficient N/A
Notes:

Formulary Substitutions

Criterion Compliant Deficient N/A
Formulary substitutions are anticipated Compliant Deficient N/A
Receiving-facility formulary differences are anticipated Compliant Deficient N/A
Receiving-facility formulary limitations are reviewed before transfer Compliant Deficient N/A
Notes:

Monitoring and Laboratory Handoff

Criterion Compliant Deficient N/A
Monitoring and laboratory requirements are transmitted Compliant Deficient N/A
Monitoring requirements are communicated Compliant Deficient N/A
Required laboratory follow-up is communicated Compliant Deficient N/A
Pending medication-related results are communicated Compliant Deficient N/A
Medication administration devices accompany the patient when necessary Compliant Deficient N/A
Notes:

Direct Clinician Communication

Criterion Compliant Deficient N/A
Direct clinician-to-clinician communication occurs for high-risk therapy Compliant Deficient N/A
Contact information is available for questions Compliant Deficient N/A
Unresolved medication issues are communicated directly Compliant Deficient N/A
Communication occurs within the organization’s required timeframe Compliant Deficient N/A
Notes:

Procedural Transitions

Preprocedure Holds

Criterion Compliant Deficient N/A
Preprocedure medication holds are documented Compliant Deficient N/A
Anticoagulant and antiplatelet management is reconciled Compliant Deficient N/A
Insulin and glucose-management plans are reconciled Compliant Deficient N/A
Notes:

Periprocedural Medication Changes

Criterion Compliant Deficient N/A
Periprocedural medications are distinguished from continuing therapy Compliant Deficient N/A
Intraoperative medications are visible to the receiving team Compliant Deficient N/A
Medication allergies and prior reactions remain visible Compliant Deficient N/A
Notes:

Postprocedure Restart Plans

Criterion Compliant Deficient N/A
Postprocedure restart plans are documented Compliant Deficient N/A
Held medications are identified Compliant Deficient N/A
Recent medication changes are clearly communicated Compliant Deficient N/A
Notes:

Sedation, Analgesia, and Monitoring Continuity

Criterion Compliant Deficient N/A
Analgesia and sedation plans are reconciled Compliant Deficient N/A
Monitoring requirements accompany the handoff Compliant Deficient N/A
Time of last dose is communicated when clinically relevant Compliant Deficient N/A
Time of next dose is communicated when clinically relevant Compliant Deficient N/A
Notes:

PICU or NICU Transfer

Weight and Dosing Basis

Criterion Compliant Deficient N/A
Weight and dosing basis are verified Compliant Deficient N/A
The dosing basis remains visible to the receiving intensive-care team Compliant Deficient N/A
Recent changes in dosing weight are highlighted during transfer Compliant Deficient N/A
Notes:

Infusion Concentration and Rate Continuity

Criterion Compliant Deficient N/A
Continuous infusions are reconciled Compliant Deficient N/A
Standard concentrations are confirmed Compliant Deficient N/A
Infusion concentrations and rates are communicated Compliant Deficient N/A
Continuous infusions include current dose and concentration Compliant Deficient N/A
Notes:

Titration Parameters

Criterion Compliant Deficient N/A
Titration parameters are communicated Compliant Deficient N/A
Titrated medications include current settings and parameters Compliant Deficient N/A
Recent dose changes are communicated Compliant Deficient N/A
Notes:

Neonatal or Pediatric Formulation Needs

Criterion Compliant Deficient N/A
Neonatal concentration requirements are highlighted when applicable Compliant Deficient N/A
Age-specific formulation constraints are communicated to the receiving team Compliant Deficient N/A
Special preparation needs are handed off before transfer completion Compliant Deficient N/A
Notes:

Monitoring and Rescue Readiness

Criterion Compliant Deficient N/A
Rescue medications and monitoring plans are addressed Compliant Deficient N/A
Monitoring requirements accompany the handoff Compliant Deficient N/A
High-alert medication monitoring continues without interruption Compliant Deficient N/A
Enteral and parenteral therapies are reconciled Compliant Deficient N/A
Notes:

Appendix: Transition-Specific Modules

Print only the module pages needed for the selected transition type. These appendix criteria are separated from the primary blank form.

Admission Medication Reconciliation

Criterion Compliant Deficient N/A
Medication history is initiated within the required timeframe Compliant Deficient N/A
Pre-admission medications are compared with admission orders Compliant Deficient N/A
Continue, hold, modify, or discontinue decisions are documented Compliant Deficient N/A
Time-sensitive medications are prioritized Compliant Deficient N/A
Last-dose timing is verified when important Compliant Deficient N/A
Home medication supply brought to the facility is secured and documented Compliant Deficient N/A
External records are reviewed when needed Compliant Deficient N/A
Unresolved discrepancies are escalated before routine care proceeds Compliant Deficient N/A
Notes:

Internal Unit Transfer

Criterion Compliant Deficient N/A
Active medications are reviewed before transfer Compliant Deficient N/A
Unit-specific order discontinuation is controlled Compliant Deficient N/A
Infusions are reconciled during transfer Compliant Deficient N/A
Medication administration record continuity is verified Compliant Deficient N/A
Held and delayed doses are communicated Compliant Deficient N/A
Receiving-unit formulary or storage differences are addressed Compliant Deficient N/A
High-alert medication monitoring continues without interruption Compliant Deficient N/A
Transfer orders reflect the intended regimen Compliant Deficient N/A
Notes:

Emergency Department to Inpatient Admission

Criterion Compliant Deficient N/A
Emergency medications are differentiated from continuing medications Compliant Deficient N/A
Home medications are reconciled before inpatient orders are finalized Compliant Deficient N/A
Medications administered in the emergency department are visible to the receiving team Compliant Deficient N/A
Time-critical home medications are addressed Compliant Deficient N/A
Temporary emergency orders are reviewed Compliant Deficient N/A
Last administration times are communicated Compliant Deficient N/A
Medication-related diagnostic uncertainty is handed off Compliant Deficient N/A
Caregiver-provided medication information is preserved Compliant Deficient N/A
Notes:

Operating Room or Procedural Transition

Criterion Compliant Deficient N/A
Preprocedure medication holds are documented Compliant Deficient N/A
Anticoagulant and antiplatelet management is reconciled Compliant Deficient N/A
Insulin and glucose-management plans are reconciled Compliant Deficient N/A
Periprocedural medications are distinguished from continuing therapy Compliant Deficient N/A
Intraoperative medications are visible to the receiving team Compliant Deficient N/A
Postprocedure restart plans are documented Compliant Deficient N/A
Analgesia and sedation plans are reconciled Compliant Deficient N/A
Medication allergies and prior reactions remain visible Compliant Deficient N/A
Notes:

PICU or NICU Transfer

Criterion Compliant Deficient N/A
Weight and dosing basis are verified Compliant Deficient N/A
Continuous infusions are reconciled Compliant Deficient N/A
Standard concentrations are confirmed Compliant Deficient N/A
Titration parameters are communicated Compliant Deficient N/A
Recent dose changes are communicated Compliant Deficient N/A
Rescue medications and monitoring plans are addressed Compliant Deficient N/A
Enteral and parenteral therapies are reconciled Compliant Deficient N/A
Developmental and neonatal formulation needs are considered Compliant Deficient N/A
Notes:

Interfacility Transfer

Criterion Compliant Deficient N/A
A complete medication administration record accompanies the patient Compliant Deficient N/A
Current medication orders are transmitted Compliant Deficient N/A
Last-dose times are documented Compliant Deficient N/A
Infusion concentrations and rates are communicated Compliant Deficient N/A
Medications sent with the patient are inventoried Compliant Deficient N/A
Receiving-facility formulary differences are anticipated Compliant Deficient N/A
Transport medication responsibilities are defined Compliant Deficient N/A
Unresolved medication issues are communicated directly Compliant Deficient N/A
Notes:

Hospital Discharge to Home

Criterion Compliant Deficient N/A
Final home regimen is clearly identified Compliant Deficient N/A
Caregiver education and teach-back are completed Compliant Deficient N/A
Prescription access is confirmed Compliant Deficient N/A
Medication devices are supplied Compliant Deficient N/A
Home supplies and remaining medications are reconciled Compliant Deficient N/A
Stopped medications are removed from caregiver instructions Compliant Deficient N/A
Follow-up monitoring is arranged Compliant Deficient N/A
Contact instructions are provided for medication questions Compliant Deficient N/A
Notes:

Discharge to Skilled Nursing, Rehabilitation, or Long-Term Care

Criterion Compliant Deficient N/A
The receiving facility receives the reconciled medication list Compliant Deficient N/A
Prescriptions or medication orders meet receiving-facility requirements Compliant Deficient N/A
Controlled-medication documentation is complete Compliant Deficient N/A
Medication supply during transfer is ensured Compliant Deficient N/A
Formulary substitutions are anticipated Compliant Deficient N/A
Monitoring and laboratory requirements are transmitted Compliant Deficient N/A
Medication administration devices accompany the patient when necessary Compliant Deficient N/A
Direct clinician-to-clinician communication occurs for high-risk therapy Compliant Deficient N/A
Notes:

Ambulatory or Specialty-Care Transition

Criterion Compliant Deficient N/A
Medication changes from the specialty visit are communicated to primary care Compliant Deficient N/A
Primary-care medication changes are visible to the specialty team Compliant Deficient N/A
Duplicate prescribing is assessed Compliant Deficient N/A
Monitoring responsibilities are assigned Compliant Deficient N/A
Specialty-pharmacy medications are reconciled Compliant Deficient N/A
Prior authorization and refill continuity are addressed Compliant Deficient N/A
Medication list updates are shared with the caregiver Compliant Deficient N/A
Follow-up timing is documented Compliant Deficient N/A
Notes:

Custom Transition

Institution-defined transition: ______________________________________________

Local transition-specific criteria:

Notes: