Medication Reconciliation

Reconcile home medications against admission and discharge medication plan

Patient

Kavya Sharma

UHID

UH-2026-0712

Discharge Date

23 Jun 2026

3 items on hold

Review before discharge

Medication	Dose/Freq	Route	Reason	Reconciliation Action	Notes
Metformin 500 mg	BD	Oral	T2DM	Hold	Hold peri-operatively. Resume when tolerating oral diet
Amlodipine 5 mg	OD	Oral	Hypertension	Continue	—
Aspirin 75 mg	OD	Oral	IHD	Hold	Held 7 days pre-op. Resume post-op day 5 after haemostasis confirmed.
Atorvastatin 40 mg	OD	Oral	Dyslipidaemia	Continue	—
Pantoprazole 40 mg	OD	Oral	GERD	Continue	—
Glipizide 5 mg	OD	Oral	T2DM	Hold	Hold — switch to insulin sliding scale while NPO

Medication	Dose/Freq	Route	Indication
IV Pip-Tazo 4.5 g	Q8h	IV	Peritonitis — post-op antibiotic
Insulin Actrapid	Sliding scale	SC	Glycaemic management — periop
IV Morphine PCA	2 mg Q10min PRN	IV PCA	Post-operative analgesia

Pharmacist

Date

I confirm this medication reconciliation is accurate and the discharge prescription has been reviewed and verified.