ALLERGIES/ADR
MRT5 – Allergies/ADRs
FACILITY ALLERGY/ADR
No Remote Allergy/ADR Data available for this patient
LOMA LINDA HCS No Known Allergies
MEDICATIONS
MRR1 – Med Reconciliation
INCLUDED IN THIS LIST: Alphabetical list of active outpatient
prescriptions dispensed from this VA (local) and dispensed from another
VA or DoD facility (remote) as well as inpatient orders (local pending and
active), local clinic medications, locally documented non-VA medications,
and local prescriptions that have expired or been discontinued in the past
90 days.
Non-VA Meds Last Documented On: May 06, 2022
*
***NOTE*** The display of VA prescriptions dispensed from another VA or
DoD facility (remote) is limited to active outpatient prescription entries
matched to National Drug File at the originating site and may not include
some items such as investigational drugs, compounds, etc.
NOT INCLUDED IN THIS LIST: Medications self-entered by the patient into
personal health records (i.e. My HealtheVet) are NOT included in this
list. Non-VA medications documented outside this VA, remote inpatient
orders (regardless of status) and remote clinic medications are NOT
included in this list. The patient and provider must always discuss
medications the patient is taking, regardless of where the medication was
dispensed or obtained.
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INPT ACETAMINOPHEN 325MG TAB U/D (Status=Active)
650MG BY MOUTH EVERY FOUR HOURS AS NEEDED For mild
pain (1-3)/HA/Temperature>101.4F **DO NOT TAKE MORE
THAN 3000MG OF ACETAMINOPHEN PER DAY** Indication:
FEVER
OUTPT ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL (Status = Active)
INHALE 2 PUFFS BY MOUTH EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF
BREATH
Rx# 11761293 Last Released: 5/22/25 Qty/Days Supply: 2/30
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: FOR SHORTNESS OF BREATH
INPT ALBUTEROL 3/IPRATROP 0.5MG/3ML INHL 3ML (Status=Active)
1 VIAL INHL EVERY SIX HOURS RESPIRATORY While awake
Indication: FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
OUTPT ATENOLOL 50MG TAB (Status = Discontinued)
TAKE ONE TABLET BY MOUTH DAILY FOR BLOOD PRESSURE AND HEART RATE
CONTROL
Rx# 10378684C Last Released: 3/6/25 Qty/Days Supply: 90/90
Rx Expiration Date: 3/1/26 Refills Remaining: 3
OUTPT BUDESONIDE 160/FORMOTER 4.5MCG 120D INH (Status = Active)
INHALE 2 PUFFS BY MOUTH TWICE A DAY FOR CHRONIC OBSTRUCTIVE
PULMONARY DISEASE **APPROVED TO REPLACE WIXELA**
Rx# 11550594 Last Released: 6/9/25 Qty/Days Supply: 3/90
Rx Expiration Date: 8/17/25 Refills Remaining: 0
Indication: FOR BRONCHOSPASM COPD
CLIN CEFEPIME HCL 2GM/NS 100ML INJ,SOLN (Status=Discontinued)
CEFEPIME INJ,PWDR 2 GM in SODIUM CHLORIDE 0.9% INJECT
50 ml IVPB INFUSE OVER 30 Minutes ONE-TIME STAT
Administer in ED. Indication: ASDFASF <ORDER
DISCONTINUED>
CLIN CEFEPIME INJ,PWDR (Status=EXPIRED)
Change CEFEPIME INJ,PWDR 2 GM in SODIUM CHLORIDE 0.9%
INJECT 100 ml IVPB INFUSE OVER 30 Minutes ONE-TIME
STAT Administer in ED. Indication: ASDFASF
BCMA ORDER LAST ACTION: 06/12/25 23:26 GIVEN
INPT CEFEPIME INJ,PWDR (Status=Pending)
CEFEPIME INJ,PWDR 2 GM in IVPB EVERY EIGHT HOURS STAT
Proven infection. Organism: Give for 7 days Weight:
- 9 lb [97.48 kg] (05/22/2025 14:44) Height: 71 in
[180.3 cm] (07/11/2019 13:53) Creatinine: 06/12/25
CREATININE,SERUM 1.01 Indication: FOR PNEUMONIA
Non-VA CETIRIZINE HCL 10MG TAB
TAKE ONE TABLET BY MOUTH DAILY May 06, 2022
OUTPT DIAZEPAM 10MG TAB (Status = Active)
TAKE ONE TABLET BY MOUTH TWICE A DAY AS NEEDED ANXIETY HOLD FOR
SEDATION
Rx# 11761321 Last Released: 5/22/25 Qty/Days Supply: 28/14
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: ANXIETY
INPT DOCUSATE NA 250MG CAP UD (Status=Active)
250MG BY MOUTH DAILY AS NEEDED Indication: FOR
CONSTIPATION
OUTPT EMPAGLIFLOZIN 25MG TAB (Status = Active)
TAKE ONE-HALF TABLET BY MOUTH DAILY FOR CHRONIC HEART FAILURE
Rx# 11761296 Last Released: 5/22/25 Qty/Days Supply: 15/30
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: FOR CHRONIC HEART FAILURE
INPT EMPAGLIFLOZIN 12.5MG HALF-TAB UD (Status=Active)
- 5MG BY MOUTH DAILY Indication: FOR CHRONIC HEART
FAILURE
OUTPT FUROSEMIDE 40MG TAB (Status = Active)
TAKE ONE TABLET BY MOUTH DAILY AS NEEDED EDEMA (HOLD FOR SYSTOLIC
BLOOD PRESSURE LESS THAN <95 MMHG) WATER PILL
Rx# 11761300 Last Released: 5/22/25 Qty/Days Supply: 30/30
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: EDEMA
INPT GUAIFENESIN 400MG TAB (Status=Pending)
400MG BY MOUTH THREE TIMES A DAY AS NEEDED
Indication: FOR COUGH
CLIN LEVALBUTEROL HCL 0.63MG/3ML INHL SOLN (Status=EXPIRED)
- 63MG/3ML INHL ONE-TIME STAT Indication: ASDFASDF
BCMA ORDER LAST ACTION: 06/12/25 21:48 GIVEN
Non-VA MAGNESIUM OXIDE 400MG TAB
TAKE ONE TABLET BY MOUTH DAILY Jul 29, 2019 **NOTICE:
OTC ITEM – NO FURTHER FILLS ALLOWED** product
INPT METHYLPREDNISOLONE ACET 40MG/ML 1ML VI (Status=Active)
40MG/1ML INTRAMUSCULARLY EVERY EIGHT HOURS
Indication: CHRONIC OBSTRUCTIVE PULMONARY DISEASE
EXACERBATION
OUTPT METOPROLOL SUCCINATE 25MG SA TAB (Status = Active)
TAKE THREE TABLETS BY MOUTH DAILY AFIB (HOLD FOR SYSTOLIC BLOOD
PRESSURE LESS THAN <100 OR HEART RATE LESS THAN <55)
Rx# 11761307 Last Released: 5/22/25 Qty/Days Supply: 60/20
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: AFIB
INPT METOPROLOL SUCCINATE 25MG SA TAB (Status=Active)
75 MG BY MOUTH DAILY Indication: AFIB
INPT ONDANSETRON HCL 2MG/ML INJ 2ML VI (Status=Active)
4MG/2ML IV EVERY SIX HOURS AS NEEDED Indication:
NAUSESA
OUTPT PREDNISONE 20MG TAB (Status = Active)
TAKE TWO TABLETS BY MOUTH DAILY COPD EXCERBATION
Rx# 11761317 Last Released: 5/22/25 Qty/Days Supply: 10/5
Rx Expiration Date: 6/21/25 Refills Remaining: 0
Indication: COPD EXCERBATION
OUTPT RIVAROXABAN 20MG TAB (Status = Discontinued)
TAKE ONE TABLET BY MOUTH DAILY WITH LARGEST MEAL OF THE DAY FOR
BLOOD CLOT PREVENTION*APPROVED*
Rx# 9375454F Last Released: 12/12/24 Qty/Days Supply: 90/90
Rx Expiration Date: 5/9/25 Refills Remaining: 1
OUTPT RIVAROXABAN 20MG TAB (Status = Active)
TAKE ONE TABLET BY MOUTH DAILY WITH LARGEST MEAL OF THE DAY FOR
BLOOD CLOT PREVENTION*APPROVED*
Rx# 9375454G Last Released: 5/27/25 Qty/Days Supply: 90/90
Rx Expiration Date: 8/20/25 Refills Remaining: 0
INPT RIVAROXABAN 20MG TAB (Status=Active)
20MG BY MOUTH DAILY Indication: FOR PREVENTION OF
BLOOD CLOTS
OUTPT SIMVASTATIN 10MG TAB (Status = Active)
TAKE ONE TABLET BY MOUTH AT BEDTIME FOR HIGH CHOLESTEROL
Rx# 10869620C Last Released: 3/5/25 Qty/Days Supply: 90/90
Rx Expiration Date: 11/16/25 Refills Remaining: 2
Indication: FOR HIGH CHOLESTEROL
INPT SIMVASTATIN 10MG TAB (Status=Active)
10MG BY MOUTH AT BEDTIME Indication: FOR HIGH
CHOLESTEROL
CLIN SODIUM CHLORIDE 0.9% INJ (Status=Discontinued)
SODIUM CHLORIDE 0.9% INJECT 250 ml IV 250 ml/hr STAT
To be administered in the ED. Indication: ASDFAS
<AUTO DC>
BCMA ORDER LAST ACTION: 06/12/25 21:30 INFUSING
CLIN VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=Discontinued)
Discontinue VANCOMYCIN 5MG/ML PREMIX BAG INJECT 350
ml IVPB INFUSE OVER 180 MINUTES ONE-TIME STAT
Indication: ASDFASDF <ORDER DISCONTINUED>
CLIN VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=EXPIRED)
Change VANCOMYCIN 5MG/ML PREMIX BAG INJECT 400 ml
IVPB INFUSE OVER 180 MINUTES NOW STAT Indication
ASDFASDF
BCMA ORDER LAST ACTION: 06/12/25 23:26 GIVEN
INPT VANCOMYCIN 5MG/ML PREMIX BAG INJ (Status=Pending)
VANCOMYCIN 5MG/ML PREMIX BAG INJECT 250 ml IVPB
INFUSE OVER 150 Minutes EVERY TWELVE HOURS Vancomycin
dosing per P&T Approved Pharmacy Protocol Indication:
- High Risk for MRSA due to MRSA colonizer or on IV
antibiotic w/in 90 days Duration of therapy: 7 days
NEW Therapeutic target for all indications
AUC/MIC-24 (aka. AUC24) = 400-600 hr*mg/L Is patient
less than 52 years of age and of female birth sex?*
No Is patient able to conceive?* N/A patient is >= 52
years old and/or not of female birth sex as above
Indication: FOR PNEUMONIA
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SUPPLIES
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MEDICATION HISTORY
=
Local and Remote Allergies/ADRs were reviewed and confirmed with
patient/caregiver? YES
Were remote allergies found upon review? see above
VALL/DOD Active Outpatient Medications were reviewed with patient/caregiver?
YES
Non-VA Medications were discussed with patient/caregiver?: YES
Remote VA Medications were discussed with patient/caregiver?: YES
Essential Medication List for review (EMLR) has been reviewed with
patient/caregiver? YES
Refill history reviewed with patient/caregiver?: YES
=
MEDICATION REVIEWED
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MEDICATION INTAKE HISTORY ADMISSION ASSESSMENT
Patient is a 78 y.o. MALE seen in the Emergency Department today. Medication
intake history conducted at this encounter.
Patient is being admitted to . Interviewed patient to complete medication
reconciliation and fill medications needing refills. Patient is actively
taking these medication unless otherwise note.
Source of Information: Patient son
Spoke with the patient/caregiver at the ED bedside. Patient was verified
with two ID’s. YES
New Allergies/ADRs found?: NO
=
HOME MEDICATIONS & DISCREPANCIES
=
- ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL INHALE 2 PUFFS BY ACTIVE
MOUTH EVERY 4 HOURS AS NEEDED
Indication: FOR SHORTNESS OF BREATH
- BUDESONIDE 160/FORMOTER 4.5MCG 120D INH INHALE 2 PUFFS BY ACTIVE
MOUTH TWICE A DAY FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
**APPROVED TO REPLACE WIXELA**
Indication: FOR BRONCHOSPASM COPD
- DIAZEPAM 10MG TAB TAKE ONE TABLET BY MOUTH TWICE A DAY AS ACTIVE**
NEEDED HOLD FOR SEDATION
Indication: ANXIETY
- EMPAGLIFLOZIN 25MG TAB TAKE ONE-HALF TABLET BY MOUTH DAILY ACTIVE
Indication: FOR CHRONIC HEART FAILURE
- FUROSEMIDE 40MG TAB TAKE ONE TABLET BY MOUTH DAILY AS NEEDED ACTIVE
(HOLD FOR SYSTOLIC BLOOD PRESSURE LESS THAN <95 MMHG) WATER
PILL
Indication: EDEMA
- METOPROLOL SUCCINATE 25MG SA TAB TAKE THREE TABLETS BY MOUTH ACTIVE
DAILY (HOLD FOR SYSTOLIC BLOOD PRESSURE LESS THAN <100 OR
HEART RATE LESS THAN <55)
Indication: AFIB
- PREDNISONE 20MG TAB TAKE TWO TABLETS BY MOUTH DAILY ACTIVE
Indication: COPD EXCERBATION
- RIVAROXABAN 20MG TAB TAKE ONE TABLET BY MOUTH DAILY WITH ACTIVE**
LARGEST MEAL OF THE DAY FOR BLOOD CLOT PREVENTION*APPROVED*
- SIMVASTATIN 10MG TAB TAKE ONE TABLET BY MOUTH AT BEDTIME ACTIVE**
Indication: FOR HIGH CHOLESTEROL
78 years old male patient presented with afib, shortness of breath; patient’s
son over the phone reports that
a) patient takes above home meds as ordered, but has NOT taken any medication
today, 6/12; also, patient took the last dose of rivaroxaban 3 days ago and
simvastatin 2 days ago.
b) patien takes amoxillin, prednisone, and levalbuterol neb from nonVA provider.
c) patient was found with an empty diazepam bottle around 1pm on 6/12, and is
suspected to have taken >10 pills of diazepam prior to OSH ER visit.
No new allergy reported, OTC includes cetirizine, mag, potassium, mucinex; no
refill requested today.
PBM PharmD Pharmacotherapy Rem V12
Address adherence
Medication monitoring or diagnostic evaluation (e.g., other labs, EKG)
Medication reconciliation (changes to active VA and non-VA medication lists
to reconcile differences)
No changes to medication lists made (medication review completed, no
discrepancies identified)
Prevent or manage an adverse drug reaction or event
Inpatient Clinical Pharmacist