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Patient Name / Patient Number: ____________________________________________________
Person Completing Review: ______________________________________________________
Date: ________________________________
- How many prescription medicine containers did the patient bring in? ________________________________
- 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.
- How many prescription medicines did you review with the patient? ________________________________
- 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.
- Did you ask the patient what each medicine you reviewed was for (i.e., why he/she should take it)?
___ Yes.
___ No
- Was the patient able to tell you the correct reason for taking each medicine?
___ Yes.
___ No
- Did you ask the patient how and when he/she should take each of the medicines you reviewed?
___ Yes.
___ No
- Was the patient able to tell you correctly how and when each medicine should be taken?
___ Yes.
___ No
- Were problems found with the patient's medicine regimen?
___ Yes.
___ No (skip to question 13).
- 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: ________________________________
- Did any of these problems represent a possible risk to patient safety?
___ Yes.
___ Possibly.
___ No.
- Would any of these problems explain negative symptoms the patient has been experiencing?
___ Yes.
___ Possibly.
___ No.
___ Not applicable (patient not experiencing negative symptoms).
- Were changes made to the medicine regimen because of the review?
___ Yes.
___ No. Thank you for completing this form. You are now done.
- 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.
- 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: ________________________________