Medication reconciliation begins with a reliable history of what the patient actually takes. An old electronic list is a starting point, not proof that every entry is current. The nursing interview can uncover recent changes, occasional medicines, and details that need pharmacist or prescriber verification.

The AHRQ MATCH toolkit describes reconciliation as comparing the current regimen with admission, transfer, or discharge orders to identify discrepancies. Collecting the history and resolving differences are connected but distinct steps.

Start with an ordinary day

Ask the patient to walk you through the medicines they take from waking up to bedtime. Then ask about medicines used weekly, monthly, or only when needed. A routine-based conversation can produce more detail than reading a list and asking whether it looks right.

Try this original prompt: “What did you take yesterday, including anything you used only once?” Follow with questions about the name, dose, and last use. Record uncertainty explicitly rather than filling a gap from memory.

Check more than prescription tablets

AHRQ’s medication interview prompts include prescriptions, nonprescription products, vitamins, supplements, and medicines used through other routes. Ask about inhalers, patches, injections, drops, and skin preparations as well as pills.

  • “What do you use when you have a headache or trouble sleeping?”
  • “Are there any medicines you apply to your skin or use in your eyes?”
  • “Has anyone recently started, stopped, or changed a medicine?”
  • “When did you last take each medicine that is not used every day?”

For each item, clarify the formulation, strength, actual dose, route, frequency, and last dose when possible. A brand name alone may not identify the preparation.

Separate the label from actual use

A patient may take a medicine differently from the directions because of side effects, cost, confusion, or another reason. Ask neutrally. “How are you taking it now?” invites a more useful answer than “You take this correctly, right?”

The AHRQ medicine review tool recommends discussing how medicines are used and checking containers when available. Follow facility procedures for handling medicines brought from home. A bottle or dispensing history is useful evidence, but it does not establish exactly what was swallowed or when.

Make the uncertain item easy to resolve

An illustrative discrepancy might be an electronic list showing one tablet daily while the patient reports that the prescriber changed it to half a tablet. Record both accounts and the source, then refer the question through the reconciliation process. Do not silently choose one or independently change the order.

When the patient cannot provide the details, follow the approved process for contacting a caregiver, community pharmacy, or other source. Clearly distinguish a verified item from an entry still awaiting confirmation.

Close the loop with the patient and team

Communicate unresolved discrepancies before they become assumptions at the next transition. Include what remains unknown, who is checking it, and whether a time-sensitive dose is approaching. The final plan should be explained in terms the patient can use, including which medicines have changed and which questions need follow-up.

Our medication administration rights refresher covers a related bedside check. It complements reconciliation but does not replace obtaining and verifying the medication history.