MEDICATION-FREQUENCY CLARIFICATION RECORD

SOURCE AND DISCREPANCY
Patient identifiers checked in the clinical system:
Medicine, formulation, strength, dose and route:
Source document or order identifier / date / current status:
Exact frequency wording in each conflicting source:
What remains unclear:
Last dose: amount, time and information source, or unknown:

VERIFICATION
Person contacted / role / request time:
Actual response time and authorizing clinician:
Confirmed frequency in words and any timing conditions:
Patient-specific instructions for the next dose:
Authorized order or clarification reference:

RECONCILIATION AND COMMUNICATION
Active order, medication list, label and patient instructions checked:
Corrections completed / by whom / time:
Original source and correction history location:
Instructions communicated / recipient / time:
Patient's explanation back / remaining questions:
Unresolved task / owner / agreed checkpoint and escalation route:
Entry author / role / date and time: