Download Appendice A - Medication Review Forms

Appendice A - Medication Review Forms
What is a Medication Review?
 A Medication Review is a service
that involves your pharmacist
performing a complete assessment
of your medications
What benefits are there from having a
Medication Review?
 Address any questions or concerns
that you have about your medicine
 Ensure that you are receiving the
best medicine therapy possible
 Increase your knowledge about
your medicine
 Increase your confidence in using
your medicine
 Reduce your risk of problems from
your medicine
 Are you taking several medications
 Do you ever have trouble using your
(including natural products and non-
medicines (swallowing, puffers, eye
prescription products)
drops, patches)
 Do you have more than one doctor
or other health care provider
 Do any of your medications make
you feel unwell
 Does the cost of your medicine
make it hard for you to take it as
prescribed
 Do you have trouble understanding
or remembering how to take your
medicine
 Do you feel that you are taking too
many medicines
 Do you worry that your medicines
are working against each other
 Have you recently been discharged
from the hospital
 Do you wish you knew more about
your medicine
Pharmacy Contact Information Here Patient Name: PHIN: DOB: Pharmacist: Phone: Best Possible Medication History 1. Patient Information
Name Gender q Male Age Third Party Coverage Family Physician qFemale Address Postal Code Reason for Med Review qUndifferentiated City/Province Phone # Other Physician/Specialist Caregiver (if applicable) Phone # Pharmacist Completing Review License No. What is your primary concern about your medications today? What are your expectations from your medications, and what would like to achieve from your med review today? 2. Consent
q I have received information on, and have consented to review process Patient Signature:_ q I have agreed that information may be shared with my physician and other healthcare providers Patient Signature:_ q I consent to having my patient representative/caregiver involved in medication review (if applicable) Name of Representative(s):_ Patient Signature: Clear selection
Pharmacy Contact Information Here Patient Name: PHIN: DOB: Pharmacist: Phone: 3. Health Information and Lifestyle Factors
Inquiry Yes/No Details/Comments a. Allergies
qY qN Reaction: b. Smoker
c. Alcohol Consumption
qY qN qFormer Smoker qY qN Cigarettes/day: X years Drinks/week: d. Caffeine Intake
qY qN Cups/day: e. Grapefruit (Juice) Consumption
qY qN Comments:
f.
qY qN qRestricted Diet qY qN Type of activity: Is now a good time to quit?
Nutritious Diet
g. Physically Active
Minutes/week: h. Recreational/Other Drug Use
qY qN i.
Yearly Influenza Immunization
qY qN j. Pneumococcal Immunization
(if ver 65) k. Other Vaccinations
(travel, routine, etc.)
l. Screening Completed
(breast, colon, cervical, etc.)
m. Eye Exam, Hearing test within
last year
qY qN n. Regular or recent lab tests
qY qN Date/Result: Height: p. Do you live alone?
qNormal qOverweight qUnderweight qY qN q. Aids, Alerts, Devices, etc.
Other qY qN Please list: qY qN What/When: qY qN (copy & attach results if possible)
o. Body Mass Index (BMI)
Weight: Clear selection
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters)
 Kidney Disease?
CrCl =
 Liver Disease?
BP =
HR =
RR =
Y N NA Pregnant? Trimester:
Y N NA Breastfeeding?
E.g. Diabetes
Type II, diagnosed in ___
HgA1C = 7.2% (mm/yyyy)
Tests 3 times daily (blood glucose diary
copied and attached), sees foot specialist
on regular basis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Head to toe Assessment regarding other complaints/concerns/bothersome symptoms:
Complaints/Concerns:
Bothersome symptoms:
Do any ever require self treatment?
Family History
Clear selection
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)
Medication
Name, Strength
How Taken
Dose, Route, Frequency, Time
of Day, Special Instructions
Purpose for Use
How long taken
Issues Identified
Yes:
Proceed
to DTPs
Identified
No:
Verify to
continue
as per
Additional
Comments
Clear Selection
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
6. Recently Discontinued Medications
Medication
Name, Strength
How Taken
Dose, Frequency, Time of Day,
Special Instructions
Purpose for Use
How long taken?
When was stopped?
Who stopped it?
Reason for Stopping?
Require Further
Action?
Yes:
Proceed
to DTPs
Identified
No:
Verify to
continue
as per
Clear selection
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Drug Therapy Problems Identified

No drug therapy problems were identified
Priority Number
Drug Therapy Problem (DTP)
_____
_________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
For those drug therapy problems above which can be corrected with immediate action and no
further research or consultation, document your plan below:
DTP
#
Proposed solution
Discussed
with
patient
Follow-up Plan
For those drug therapy problems requiring further research, contact with other health care
providers and care plan development, utilize the Pharmacy Care Plan worksheet.
____________________________________
Pharmacist signature
__________________________
Date of Review
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Pharmacy Care Plan
Data: Subjective information provided by the patient and/or objective data that you have
collected.
Assessment: State the drug therapy problem.
Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence,
cost, drug coverage and non-pharmacological interventions.
Alternative #1:
Alternative #2:
Monitoring:
Planned date of follow-up: ____________________________
____________________________________
__________________________
Pharmacist signature
Date of Review
Pharmacy Contact Information Here
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Patient Action Plan
Date of Comprehensive Medication Review: _________________________
As a result of my comprehensive medication review, I will do the following:
1.
2.
3.
4.
5.
6.
7.
Source: The NB Department of Health, the New Brunswick Pharmacists’ Association, and the Canadian Pharmacists Association.
(2010). Program Guidance Document, NB Pharmacheck.
Pharmacy Contact Information Here Patient Name: PHIN:
DOB: Pharmacist: Phone:
Patient Follow-­‐Record Date of Follow-­‐Up Reason for Follow-­‐up Results Pharmacist Comments & Plan Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Intervention complete? q Yes q No Any new concerns? Pharmacist signature: Clear selection
Health Care Practitioner Communication Form
Date:_______________________
Health Care Practitioner
Re: (Patient’s Name)
Address
Address
Phone #
Fax #
DOB
PHIN
Phone #
Pharmacy Contact Information Here
Pharmacist: _____________________
Dear Dr._____________________,
Your patient had a Comprehensive Medication Review completed on ________________. Listed below are my assessment(s) and recommendation(s). Please
provide a response below (if indicated) at your earliest opportunity. Should you like to discuss any of the information contained don’t hesitate to contact me.
Drug Therapy Problem
Pharmacist Recommendation
Information Only
Information Only
Pharmacist Name:
License #:
Make Changes as
Recommended
Prescriber
Comments/Revisions
Action Required 
Yes
No
Yes
No
Action Required 
Prescriber Signature:
License #:
Date:
THIS TELECOPY IS CONFIDENTIAL AND IS INTENDED TO BE RECEIVED BY THE ADDRESSEE ONLY. IF THE READER IS NOT THE INTENDED RECIPIENT THEREOF, YOU ARE ADVISED THAT ANY DISSEMINATION, DISTRIBUTION OR
COPYING OF THIS FACSIMILE IS STRICTLY PROHIBTED. USE OF THIS FORM FOR PURPOSES OR BY PERSONS, NOT AUTHORIZED UNDER THE CONTROLLED DRUGS AND SUBSTANCES ACT AND ITS REGULATIONS IS A CRIMINAL
ACT. PRACTITIONER CERTIFICATION: THIS PRESCRIPTION REPRESENTS THE ORIGINAL OF THE PRESCRIPTION DRUG ORDER, THE PHARMACY ADDRESSEE NOTED ABOVE IS THE ONLY INTENDED RECIPIENT AND THERE ARE NO
OTHERS, THE ORIGINAL PRESCRIPTION HAS BEEN INVALIDATED AND SECURELY FILED AND IT WILL NOT BE TRANSMITTED ELSEWHERE AT ANOTHER TIME, QUANTITY MUST BE STATED IN WORDS AND NUMERALS
Form adapted from: The Ontario Pharmacists Association, MedsCheck.
Clear selection