Clinical Documentation HubGuidance, templates, and job aids for providers

Problem list and medication reconciliation

Keep the problem list current and reconcile medications at every transition.

Audience: Providers, nursing, pharmacy | Updated 2026-08-30

Problem list

  • Review the active problem list at each visit. Resolve, update, or add entries as needed.
  • Use standardized terminology so entries map to coded concepts.

Medication reconciliation

  • Reconcile at admission, transfer, discharge, and at least annually in primary care.
  • Document the source of each medication list and any discrepancies resolved.