Standards › Standard S4 › Forms
Form · LTC-FRM-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S4 (Long-term care), criterion S4.4
Purpose
Records each medicine compared at a change of care, each difference and the decision.
How to complete
- Complete at admission, transfer and discharge.
- Record each difference and the prescriber’s decision.
- Give a copy of the final list to the resident and the next provider.
Record fields
| Medicine and dose | On the resident’s own list | On the home’s list | Difference (none, missing, changed, extra) | Prescriber decision | Date and signature |
|---|---|---|---|---|---|
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO High 5s medication reconciliation standard operating protocol (2014). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)