002518.outptmedicationreconciliation

PATIENT CONTRAST ASSESSMENT FLOWSHEET
For Contrast Only – MRI (gadolinium), Gastrograffin, and Barium studies are excluded
Initial History –
* If changes in history – document change, date and initial.
History of DiabetesPresently taking: (Circle)Glucophage/Metformin Other Drug controlling Diabetes: ________________________________ NOTE: If the patient is taking another oral diabetic drug other than the above medications, call Pharmacy for instructions.
History of Kidney ProblemsCurrently or ever been on dialysisHistory of cancer – Type – Reaction to Contrast given by a radiology procedure or cardiac catheterizationPregnantPatient has had an out-patient study/procedure with contrast in the last 72 hours, notify physician.
Are there any previous contrast studies within 72 hours in the chart (Radiology or Cath Lab)? If yes, notify performing physician.
Initial History Date:
Signature:
Lab Findings & Review of History
Most recent BUN & Creatinine results:
Creatinine
Physician
Reviewed
Notify physician, if lab pending.
Notified
History with
Creatinine (normal range = 0.5-1.3 mg/dl) procedure
Contrast Procedure (to be performed):
Cumulative Contrast Use
Notification to
Amount of
Signature
performing MD
Contrast
contrast
Given for
CONTRAST
of total contrast
within 72 hours -
within 72
procedure
(within the
procedure
For Intravenous Contrast - Insertion and Administration
IV inserted by
Infusing Site During
Signature
& Post-Procedure
Dry & Intact, no Sign of swellingSee comment Dry & Intact, no Sign of swellingSee comment Dry & Intact, no Sign of swellingSee comment Dry & Intact, no Sign of swellingSee comment Dry & Intact, no Sign of swellingSee comment Methodist Le Bonheur Healthcare
OUTPATIENT MEDICATION RECONCILIATION
Patient Name:_____________________________ Ht:____ Wt:____ No Home Medications (including over the counter drugs & herbal preparations) Unable to Obtain Medication History – Reason ____________________________________ Current Home Medications (Including Over the Counter Drugs & Herbal Preparations)
Above is a list of medications this patient or his/her representative told us he/she was taking before coming to the
hospital. The physician has reviewed these medications to see if there is any conflict with new medications the
patient is being prescribed and will be taking after discharge. Unless marked “STOP TAKING” the patient wil
be instructed to continue taking these medications as described in SPECIAL INSTRUCTIONS. The patient
will be encouraged to review these medications with his/her personal physician on a regular basis.
List of Additional Medications Prescribed in Patient Friendly Terms
(To Be Completed by Physician or Clinical Staff Member)
Name of next physician patient is scheduled to visit___________________

Source: http://www.methodisthealth.org/dotAsset/2e390d72-4343-4a35-8d15-e74f858d35c4.pdf