Can this form be e-signed?

Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, electronic signatures are legally valid when intent, consent, attribution, and record retention are satisfied.

Is a Business Associate Agreement required?

If a third-party eSignature provider will handle protected health information, organizations must execute a HIPAA Business Associate Agreement before storing or transmitting PHI.

What if medication changes after signing?

Record the amendment with date, clinician name, and reason. New changes should be signed or initialed; maintain both original and amendment for auditability.

Who must sign the review?

The clinician responsible for the review should sign. Delegated pharmacists or nurses may contribute with attestation fields; institutional policy determines role authority.

How long must records be kept?

Follow HIPAA six-year retention baseline (45 CFR §164.530(j)); extend retention per state law or accreditor requirements where applicable.

What if a patient refuses electronic records?

Provide a paper alternative when required by ESIGN consumer-disclosure rules; document the patient’s choice and obtain consent or refusal in writing.

Electronic Signature
Templates
Healthcare
Healthcare Review of Medications

Healthcare Review of Medications

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE REVIEW OF MEDICATIONS

Patient Name: Date of Birth:

Patient Information

Gender Address Primary Phone Emergency Contact (Name and Relationship) Emergency Contact Phone

Insurance Information

Insurance Provider Policy Number Group Number Subscriber Name (if different)

Allergies & Adverse Reactions

Known Allergies (medication, food, environmental):

Current Medications

Provide all prescription and over-the-counter medications, herbal supplements, vitamins, inhalers, topical agents, and PRN medications.

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication Changes and Adherence

Have you discontinued or changed any medication within the last 30 days? Yes No

If yes, list medication(s) discontinued or changed and reason

Do you take your medications exactly as prescribed? Yes No

If no, explain missed doses or barriers to adherence

Adverse Effects / Concerns

Have you experienced any new or worsening side effects?

Yes No

If yes, describe symptoms, onset, severity, and actions taken

Pharmacy and Medication Sources

Preferred Pharmacy Name and Location Do you use any online/mail-order pharmacy services?

Yes No

Certification, Authorization, and Privacy Notice

I certify under penalty of law that the information provided on this Review of Medications is complete and accurate to the best of my knowledge. I understand that omissions or misstatements may affect clinical decisions and treatment planning.

I authorize my healthcare providers and the authorized care team to review and record the medication information I have provided, to contact my pharmacy or prescribers to reconcile medications, and to include this information in my medical record. This authorization is valid for the purposes of care coordination and medication safety.

I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it. This review does not alter other consent or authorization requirements for release of medical information beyond the scope necessary for medication reconciliation and patient care.

Authorization Expiration Date (if any)

Warning: Deliberate falsification of medical records or medication information may subject the signer to civil or criminal penalties under applicable law and institutional policy.

Patient / Authorized Signer (Print Name):

Signature:

Relationship to Patient (if signer is not patient):

Date:

What the Healthcare Review of Medications Is

A Healthcare Review of Medications is a structured clinical document recording a patient’s current medications, recent changes, allergies, and known interactions to support safe prescribing and administration. It typically includes medication reconciliation, verification of indications and dosing, monitoring plans, and prescriber attestation. Organizations use it to reduce adverse drug events, coordinate care across settings, and create an auditable record of medication decisions. This document may be integrated into an electronic health record (EHR) or stored as a clinical form and should be accurate, dated, and signed by the responsible clinician.

Why a Formal Medication Review Matters

A documented review reduces medication errors, supports clinical decisions, and provides an auditable record for compliance with HIPAA and facility policies. It centralizes information for care teams and helps identify duplications, omissions, and harmful interactions.

Who Completes and Relies on This Review

Typical authors and recipients of the Healthcare Review of Medications include clinicians directly responsible for prescribing and medication reconciliation.

Attending physicians and nurse practitioners who confirm indications, dosing, and follow-up.
Clinical pharmacists who verify interactions, suggest alternatives, and document reconciliation.
Nurses and care coordinators who collect home med lists and confirm administration details.

The document supports cross-discipline communication and must be accessible to the entire care team while respecting privacy and access controls.

Essential Information to Include

Patient Name: Full legal name as on ID

Date of Birth: MM/DD/YYYY format

Medical Record Number: Facility MRN or unique identifier

Active Medication List: Drug name, dose, route, frequency

Allergies/Intolerances: Agent and reaction described

Prescriber: Name, role, signature/date

Risks and Consequences of Inaccurate Reviews

Adverse Drug Event: Patient harm from interactions

Regulatory Noncompliance: Violations of facility rules

HIPAA Exposure: Unauthorized PHI disclosure risk

Medication Errors: Incorrect dose or omission

Liability Claims: Malpractice exposure increases

Care Delays: Treatment postponed pending clarification

Common Preparation Challenges

Incomplete home medication lists or patient recall gaps lead to inaccurate reconciliation and potential dosing errors.
Unclear documentation of recent changes or taper schedules causes confusion for follow-up prescribers and pharmacists.
Failure to record allergies or adverse reactions increases the risk of prescribing contraindicated drugs.
Using inconsistent drug naming (brand vs generic) complicates interaction checks and medication history comparisons.

Step-by-step: Completing a Healthcare Review of Medications

Follow a consistent sequence: collect history, verify current therapy, reconcile discrepancies, document decisions, and obtain required signatures or attestations.

01

Collect History: Ask patient or caregiver for all current medications.
02

Verify EHR: Compare home list to EHR and pharmacy fill data.
03

Reconcile Differences: Resolve duplications, omissions, or dose mismatches.
04

Document & Sign: Record changes, monitoring plan, and clinician signature.

Core Sections of a Professional Medication Review

A professional review groups essential elements so clinicians can rapidly assess safety and appropriateness at point of care.

Medication Reconciliation

Systematic comparison of patient-reported, EHR, and pharmacy data to identify and resolve discrepancies before continuing therapy.

Allergies & Intolerances

Clearly list agents and reaction severity so prescribing decisions avoid known harms and document rationale for tolerated agents.

Indication & Outcome

Record why each medication is prescribed and monitoring endpoints to assess effectiveness and deprescribing needs.

Dose & Administration

Document precise dosing, route, schedule, and any special instructions such as renal adjustment or administration timing.

Monitoring Plan

Specify lab monitoring, follow-up intervals, and actions for abnormal results to reduce risk of adverse events.

Clinician Attestation

Provider signs and dates the review, noting any counseling provided and communication with outpatient providers or pharmacy.

Configuring an Online Review Workflow

When digitizing the form, set authentication, field logic, notifications, and integrations to match clinical risk and privacy needs.

Field	Configuration
Authentication Level	Email + SMS code for clinicians; stronger for remote attestations
Conditional Fields	Show monitoring fields when high-risk meds are selected
Notifications	Auto-alert pharmacist or primary clinician on changes
EHR Integration	Map fields to discrete EHR elements for continuity

Where to Send or File Completed Reviews

Completed reviews should be routed to systems and stakeholders that maintain continuity of care and compliance.

Electronic Health Record: Attach as discrete clinical note or structured data entry
Pharmacy: Send reconciled list to outpatient or inpatient pharmacy
Patient Portal: Provide patient-facing medication list and counseling notes
Health Information Exchange: Share with external providers per consent and policy

Technical and Integration Considerations

Ensure chosen digital tools support secure transport, audit trails, and the file formats your EHR or document repository requires.

Document Formats: PDF, DOCX, HTML, and structured exports
Integrations: Salesforce, Microsoft 365, NetSuite, Google Workspace
Security Controls: TLS encryption and AES-256 at rest

Confirm the platform supports HIPAA Business Associate Agreements and audit logs to meet regulatory and institutional requirements.

Timing Expectations and Routine Deadlines

Clinical workflows impose time-sensitive expectations for completing and communicating medication reviews at key transition points.

Admission Review:

Complete medication reconciliation at initial admission or within 24 hours.

Transfer Update:

Reconcile meds when a patient transfers between units or facilities.

Discharge Summary:

Provide reconciled discharge medication list at time of discharge.

Routine Follow-up:

Review chronic regimens at each primary care or specialty visit.

Adverse Event Reporting:

Report serious medication events per facility policy, often within 24–72 hours.

Key Milestones in the Medication Review Lifecycle

Track the review through defined milestones to ensure timely completion, communication, and record retention.

01

Gather Medication History

Collect patient-reported and pharmacy data at presentation.

02

Reconcile & Update

Resolve discrepancies and document rationale for changes.

03

Provider Attestation

Clinician signs to confirm review and plan.

04

Archive & Share

Store in EHR and share with outpatient providers as needed.

eSignature Platform Comparison for Medication Review Workflows

Compare common vendor attributes relevant to healthcare workflows: starting price, trial availability, bulk send, audit trail, HIPAA support, and envelope caps.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card required	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions About Medication Reviews

Answers to common questions about completion, e-signing, HIPAA, updates, and storage for Healthcare Reviews of Medications.

Need help? Contact support

Can this form be e-signed?
Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, electronic signatures are legally valid when intent, consent, attribution, and record retention are satisfied.
Is a Business Associate Agreement required?
If a third-party eSignature provider will handle protected health information, organizations must execute a HIPAA Business Associate Agreement before storing or transmitting PHI.
What if medication changes after signing?
Record the amendment with date, clinician name, and reason. New changes should be signed or initialed; maintain both original and amendment for auditability.
Who must sign the review?
The clinician responsible for the review should sign. Delegated pharmacists or nurses may contribute with attestation fields; institutional policy determines role authority.
How long must records be kept?
Follow HIPAA six-year retention baseline (45 CFR §164.530(j)); extend retention per state law or accreditor requirements where applicable.
What if a patient refuses electronic records?
Provide a paper alternative when required by ESIGN consumer-disclosure rules; document the patient’s choice and obtain consent or refusal in writing.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now