Health Literacy Universal Precautions Toolkit, 2nd Edition

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Patient Name / Patient Number: ____________________________________________________

Person Completing Review: ______________________________________________________

Date: ________________________________ 
 

1. How many prescription medicine containers did the patient bring in?  ________________________________

2. Did the patient say he/she brought in all of his/her prescription medicine containers?
    ___  Yes, patient said he/she brought in all of his/her prescription medicine containers.
    ___  No, patient said he/she brought in some of his/her prescription medicine containers, but not all of them.
    ___  No, patient did not bring in any of his/her prescription medicines and supplements.
    ___  I did not check whether the patient brought in all prescription medicine containers.

3. How many prescription medicines did you review with the patient?  ________________________________

4. Did the patient say he/she brought in all of his/her over-the-counter medicines and supplements?
    ___  Yes, patient said he/she brought in all of his/her over-the-counter medicines and supplements.
    ___  No, patient said he/she brought in some of his/her over-the-counter medicines and supplements, but not all of them.
    ___  No, patient did not bring in any of his/her over-the-counter medicines and supplements.
    ___  The patient does not have any over-the-counter medicines or supplements.
    ___  I did not check whether the patient brought all over-the-counter medicines and supplements.

5. Did you ask the patient what each medicine you reviewed was for (i.e., why he/she should take it)?
    ___  Yes.
    ___  No

6. Was the patient able to tell you the correct reason for taking each medicine?
    ___  Yes.
    ___  No

7. Did you ask the patient how and when he/she should take each of the medicines you reviewed?
    ___  Yes.
    ___  No

8. Was the patient able to tell you correctly how and when each medicine should be taken?
    ___  Yes.
    ___  No

9. Were problems found with the patient's medicine regimen?
    ___  Yes.
    ___  No (skip to question 13).

10. What problems were found with the medicine regimen? Please mark all that apply.
     ___  Duplicate medicines.
     ___  Expired medicines.
     ___  Patient had contraindications for one or more medicines.
     ___  Drug-drug interactions could be possible.
     ___  Medicine was correct, but dose was incorrect.
     ___  Patient stopped taking a prescription medicine without telling you or any other clinician in this practice.
     ___  Patient stopped taking an over-the-counter medicine or supplement without telling you or any other clinician in this practice.
     ___  Patient started taking a new prescription medicine (i.e., prescribed by another doctor, prescription samples).
             without telling you or any other clinician in this practice.
     ___  Patient started taking a new over-the-counter medicine or supplement without telling you or another clinician in this practice.
     ___  Containers brought in by patient did not match the medicine list in the patient's record.
     ___  Patient not taking medicine as prescribed.
     ___  Patient failed to get medicine(s) refilled.
     ___  Patient changed to cheaper medicine.
     ___  Other—Please specify:  ________________________________

11. Did any of these problems represent a possible risk to patient safety?
     ___  Yes.
     ___  Possibly.
     ___  No.

12. Would any of these problems explain negative symptoms the patient has been experiencing?
     ___  Yes.
     ___  Possibly.
     ___  No.
     ___  Not applicable (patient not experiencing negative symptoms).

13. Were changes made to the medicine regimen because of the review?
     ___  Yes.
     ___  No. Thank you for completing this form. You are now done.

14. Did the total number of prescription medicines change as a result of the review?
     ___  Yes, the number of medicines was reduced.
     ___  Yes, the number of medicines was increased.
     ___  No, the number of medicines remained the same.

15. What other changes were made to the medicine regimen? Please mark all that apply..
     ___  Expired medicines were discontinued (thrown away).
     ___  Updated prescriptions were written for expired medicines.
     ___  Alternate medicines were prescribed to replace existing medicines.
     ___  New medicines were prescribed.
     ___  Medicine regimen was simplified (e.g., fewer doses per day).
     ___  Other—Please specify:  ________________________________

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