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TABLE OF CONTENTS
INTRODUCTION
Staff Involvement
Scheduling Appointments
Tasks for the Patient
Getting Consent
SECTION THREE: CONDUCTING A COMPREHENSIVE MEDICATION REVIEW
12
20
23
APPENDICIES: A TO H
26
CASE EXAMPLES
60
Introduction
Welcome to the Manitoba Comprehensive Medication Review Toolkit. This guide has been
developed to assist Manitoba pharmacists with the implementation of the medication review
program in their pharmacies and provide support throughout the process of performing
medication reviews for patients.
Manitoba Comprehensive
Medication Review Toolkit
How to Guide
Acknowledgements
This toolkit was a joint initiative between Manitoba Society of Pharmacists (MSP) and the
University of Manitoba Faculty of Pharmacys 4th Year Elective Program. The students involved
in its creation were Alisha McCulloch and Sarah Stroeder. We greatly appreciate the input and
guidance from MSP preceptors Britt Kural, Amy Oliver and Dr. Brenna Shearer. Thank you to
our pharmacist reviewers, who represented key stakeholders including the Manitoba
Pharmaceutical Association, University of Manitoba, MSP Professional Relations Committee and
practicing Manitoba pharmacists. Thank you also to the 4th year pharmacy students and
preceptors who were part of the pilot project in March 2013. We would like to acknowledge
the Ontario Pharmacists Association, New Brunswick Pharmacists Association and Canadian
Pharmacists Association for their excellent medication review toolkits that were a great
resource for us.
Disclaimer
The Manitoba Comprehensive Medication Review toolkit documents contain information
representing the opinions and experience of the individuals involved in program development.
Every effort has been made to provide useful and accurate information. However, MSP and
others involved in its development and review are not responsible for the use or the
consequences of the use of the tools and information in this toolkit. Users are advised that the
information presented is not intended to be all-inclusive. Consequently, pharmacists and other
users of the program are encouraged to seek additional and confirmatory information to meet
their practice requirements as well as the information needs of their patients.
Minimize risks associated with a patients medication regimen and uphold patient safety
At the conclusion of a medication review, the patient can be provided with a Best Possible
Medication History (see Appendix A) to keep for their records. This record is a comprehensive
list of Prescribed Medications, Non-prescribed Medications (OTCs), and Natural Health
Products (Herbal Products, Homeopathic Remedies, Alternative Therapies, etc) the patient
takes on a regular or intermittent basis. This record should be signed and dated by the
pharmacist and a copy retained for pharmacy records. Educate your patients to share their
comprehensive, accurate and up-to-date medication list with all health care professionals they
come in contact with.
Patients taking more than one chronic medication or is currently prescribed medication
from more than one HCP
Patient is planning for an extended period of travel, such as moving south for the winter
Referrals for medication reviews may come from you and your pharmacy team, other health
care providers or patients and their families may self-refer.
Staff Involvement
It is important to have your pharmacy staff on board with the plan to implement a medication
review service at your pharmacy because the program will require their support and
involvement in order to run most efficiently. While pharmacists are the only staff members who
can perform the actual review, other staff members can assist you with identifying potential
medication review clients, appointment scheduling and patient reminders. Pharmacy students
and interns may also perform medication reviews under the supervision of the pharmacist.
Team members can also collect the necessary forms, print a recent medication profile, and
perform demographic information gathering in preparation for the review. We encourage a
team approach to providing a quality patient care program such as this one.
Scheduling appointments
To assist your pharmacy staff in booking appointments, design a scheduling system (either
electronic or paper-based) that fits with your pharmacy workflow. The schedule should
highlight the periods of time when there is a pharmacist available to perform a comprehensive
medication review. An average medication review will take between 30-60 minutes with the
patient, in addition to some time spent preparing for the meeting and any time spent
afterwards on care plan development and further communicating with the patient as well as
the prescriber and/or other health care providers. Separate follow-up appointments should
also be scheduled in this system. See Appendix B for a sample medication review schedule.
Pharmacists may wish to maintain a separate notebook with reminders or set up electronic
reminders for follow-up calls to patients and health care practitioners.
It would be valuable for a member of your pharmacy staff to provide reminder calls to patients
for the coming days appointments. You may wish to utilize reminder cards to send home with
patients after they book an appointment. For your convenience, these cards are included in
Appendix B. Ask patients to arrive 5-10 minutes early for their appointment in order to
complete the demographic information portion of the Best Possible Medication History.
Getting Consent
Prior to beginning the medication review, direct your patients attention to the Consent section
of the Best Possible Medication History document.
Explain the medication review process, including the potential for future follow-up with
the patient to discuss any interventions put in place
Discuss the potential need to share the patients personal health information with other
health care providers (physicians, nurse practitioners, etc)
If a caregiver is present for the medication review, or is serving as the representative for
the patient, obtain consent for their involvement
It is important to obtain and document consent before proceeding with the medication review.
The pharmacist may require additional time to review the information gathered and to
complete the process outlined in this document. Please note that these problems can be
complex and may require contacting or referral to the patients family physician and/or other
health care practitioner. The pharmacist may wish to consider requesting the patient to
return for a second session to complete the medication review and discuss potential care
plans.
Are all medications at the appropriate dose for the given indication?
Are the medications that do have indications the most appropriate choice of therapy for
this patient?
o If taking more than one medication for the same condition, should they be?
2. Are there any conditions which are currently untreated that may require medication?
4. Are there any drug interactions that may exist within their current drug regimen?
Judge the relevance and necessity for intervention if drug interactions do exist
o Consider: Drug-Drug, Drug-Food, Drug-Disease
5. Is the patient receiving maximum benefit and minimal adverse effects from each medicine?
o Consider: efficacy, toxicity, drug interactions
Are all medications at the appropriate dose for the patients renal function?
o See Appendix E
Are there any medications that are hepatotoxic and require regular monitoring of liver
function tests?
Is the patient taking any medications that require assessment of drug levels?
o See Appendix F
8. Are there any other issues that affect medication use in this client?
o Consider: lack of knowledge, outdated label, caffeine/alcohol/nicotine use,
degree of communication with health care professionals, multiple health care
practitioners/pharmacies, primary prevention strategies (e.g., osteoporosis,
immunization, tobacco cessation), drug storage, drug cost, drug hoarding,
financial constraints
Sources (pp 12-15): Grymonpre, R., et al. Pharmacy Interview Guidelines, PHRM 3110 Pharmacy Skills Lab III. Faculty of
Pharmacy, University of Manitoba, Winnipeg, Manitoba.; The NB Department of Health, the New Brunswick Pharmacists
Association, and the Canadian Pharmacists Association. (2010). Program Guidance Document, NB Pharmacheck.; Amy Oliver,
B.Sc.Pharm 4th Year Elective Project Home Care Chart Review
The Pharmacy Care Plan worksheet uses the DAP (data, assessment, plan) format to organize a
concise care plan. Each drug therapy problem requiring further work-up will have a separate
care plan.
D = DATA
This section includes both subjective information to communicate the issue or complaint
expressed by the patient as well as outlines the relevant objective data collected during the
interview to support the proposed problem, assessment and plan. Avoid adding extra
information that isnt relevant as it will make the note longer and more likely that others will
miss your point. Important information may include:
A list of the medications (drug, dose, route, frequency, etc.) the patient takes relevant
to the drug therapy problem
Patients own drug taking habits and issues that may affect therapy
A = ASSESSMENT
This section is to provide a statement of the drug therapy problem based on the pharmacists
assessment. This is one sentence outlining who is experiencing (or at risk of experiencing), what
due to a drug related issue.
______________________________________________________________________________
P = PLAN
This section should be specific and outline the recommendation of how to resolve or prevent
the problem identified. If a new drug is being introduced or changed, the plan should be
justified for each specific case by including information about the efficacy, dosing, side effects,
drug interactions, convenience, cost, adherence, patient desires and third party coverage of
the option chosen. However, in other cases a suggestion may be made to stop a medication
which must also be justified. Monitoring is essential to the care plan and should include both
desired positive endpoints (efficacy) and potentially negative endpoints (adverse effects) that
are being monitored, to what magnitude, how frequently, and for how long they should be
monitored. Alternatives may also be listed, however in less detail, considering different drug
classes and regimens as well as non-drug interventions that may be beneficial. These allow for
patient and health care practitioner input to identify the ideal patient centered care plan.
A planned follow-up date is also crucial to have with the patient to monitor and gauge the
effectiveness of the chosen care plan.
Intervention guideline
The concept of patient-centered care holds exceptional value in engaging patients to
participate and take responsibility for their own health care. Pharmacists are role models in
actively including patients in making changes to their current health care regimens, as well as
developing new health care plans.
It is recommended that the patient should be involved as much as possible and have
input in suggested interventions
o Explain the situation to the patient in a way that does not undermine the health
care practitioner-patient relationship
o Avoid medical jargon and tailor your explanation to the level of the patient
o Verify patients understanding of plan: Ask patient to repeat information back, or
to demonstrate how to use medications and devices
Make sure the patient understands the need for follow-up and will participate in
monitoring
o Monitoring may involve tools such as blood pressure monitors, peak flow meters,
home glucose monitors, pain diaries, etc.
Lifestyle related interventions are common and require ongoing contact, reassurance,
and support
o E.g. Smoking Cessation
Ensure that the patient understands and is aware of proposed changes before
discussion with physician and/or other health care practitioners
Source (pp 17, 18): Grymonpre, R., et al. Pharmacy Interview Guidelines, PHRM 3110 Pharmacy Skills Lab III. Faculty of
Pharmacy, University of Manitoba, Winnipeg, Manitoba.
You may wish to provide your patient with a Patient Action Plan (see Appendix A). This is a
summary of actions to be taken as a result of the comprehensive medication review developed
in collaboration with the patient. For example, if the pharmacist discovered that the patient
was taking calcium at the same time as their levothyroxine, the pharmacist may suggest taking
these medications at separate times. This can be recorded on the Patient Action Plan as a
reminder for the patient.
For convenience, the charts found on pages 23 and 24 can be found in Appendix C and printed
as a two-sided summary page on performing a comprehensive medication review. This would
be useful to keep in your patient counseling room for quick reference while performing
comprehensive medication reviews.
Source: The NB Department of Health, the New Brunswick Pharmacists Association, and the Canadian Pharmacists Association.
(2010). Program Guidance Document, NB Pharmacheck.
Initials
Initials
Initials
Manitoba Comprehensive
Medication Review Toolkit
Appendices
prescription products)
drops, patches)
medicine
* If any oIf any of these apply to you, talk to your pharmacist about whether a Medication Review is right for you.
Phone:
Pharmacist: _____________________
Gender
Male
Age
Family Physician
Female
Address
Postal Code
Undifferentiated
City/Province
Phone #
Other Physician/Specialist
Phone #
License No.
What are your expectations from your medications, and what would like to achieve from your med
review today?
2. Consent
I have received information on, and have consented to review process
Patient Signature:______________________________________________
I have agreed that information may be shared with my physician and other healthcare
providers
Patient Signature:______________________________________________
I consent to having my patient representative/caregiver involved in medication review
(if applicable)
Name of Representative(s):_______________________________________
Patient Signature:_______________________________________________
Phone:
Pharmacist: _____________________
Inquiry
Yes/No
Details/Comments
Allergies
Y N
Reaction:
Smoker
Is now a good time to quit?
Alcohol Consumption
Y N
Former Smoker
Y N
Cigarettes/day:
x____years
Drinks/week:
Caffeine Intake
Y N
Cups/day:
Y N
Nutritious Diet
Y N
Restricted Diet
Y N
Physically Active
Type of activity:
Minutes/week:
Y N
Y N
Pneumococcal Immunization
(if over 65)
Other Vaccinations (travel, routine,
etc.)
Screening Completed (breast, colon,
cervical, etc.)
Eye Exam, Hearing test within last
year
Y N
Y N
Date/Result:
Height:
Weight:
Normal Overweight
Underweight
Y N
Other
Y N
Please list:
Y N
What/When:
Y N
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.
Family History
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
How Taken
Name, Strength
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Additional
Comments
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
How Taken
Name, Strength
Require Further
Action?
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Priority Number
_____
_________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
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
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence,
cost, drug coverage and non-pharmacological interventions.
Alternative #1:
Alternative #2:
Monitoring:
__________________________
Pharmacist signature
Date of Review
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
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.
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Results
Address
Address
Phone #
Fax #
DOB
PHIN
Phone #
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 dont 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.
on _________________ at ______________.
Please bring:
Your completed Medication Review questionnaire
ALL the medication you take (prescription, over-the-counter, natural health products)
ALL medical devices (aerochamber, glucose monitors, dosettes, etc.)
Please arrive 5-10 minutes before your appointment time.
Please call the pharmacy if you cannot make your appointment or if you have any questions.
Tuesday
NUMBER
NAME
8:oo
8:oo
9:00
9:00
10:00
10:00
11:00
11:00
12:00
12:00
1:00
1:00
2:00
2:00
3:00
3:00
4:00
4:00
5:00
5:00
Wednesday
NAME
Thursday
NUMBER
NAME
8:oo
8:oo
9:00
9:00
10:00
10:00
11:00
11:00
12:00
12:00
1:00
1:00
2:00
2:00
3:00
3:00
4:00
4:00
5:00
5:00
Friday
NAME
NUMBER
NUMBER
Saturday/Sunday
NUMBER
NAME
8:oo
8:oo
9:00
9:00
10:00
10:00
11:00
11:00
12:00
12:00
1:00
1:00
2:00
2:00
3:00
3:00
4:00
4:00
5:00
5:00
NUMBER
Are all medications at the appropriate dose for the given indication?
Are the medications that do have indications the most appropriate choice of therapy for this
patient?
o If taking more than one medication for the same condition, should they be?
2. Are there any conditions which are currently untreated that may require medication?
4. Are there any drug interactions that may exist within their current drug regimen?
Judge the relevance and necessity for intervention if drug interactions do exist
o Consider: Drug-Drug, Drug-Food, Drug-Disease
5. Is the patient receiving maximum benefit and minimal adverse effects from each medicine?
o Consider: efficacy, toxicity, drug interactions
Are all medications at the appropriate dose for the patients renal function?
o See Appendix F
Are there any medications that are hepatotoxic and require regular monitoring of liver
function tests?
Is the patient taking any medications that require assessment of drug levels?
o See Appendix G
8. Are there any other issues that affect medication use in this client?
Source: Pharmacy Practice 1998;14(5):71. Grymonpr R., Geriatric Care. How pharmacists can optimize
medication use by elderly patients.
Medication
Reconciliation
Medication
Checklist
Identification
of Drug
Therapy
Problems
Collaborative
Resolution of
Drug Therapy
Problems
Check that patients list matches what they should be taking according to
prescriptions and doctors orders, and that they are indeed taking the
medications
Ensure patient understands the indication and how to take each medication
safely and appropriately for their circumstances
Source: The NB Department of Health, the New Brunswick Pharmacists Association, and the Canadian Pharmacists Association. (2010).
Program Guidance Document, NB Pharmacheck.
Initials
Initials
Initials
A head to toe assessment is a basic review of systems to identify any further problems or symptoms
that a patient may be experiencing. This assessment should be kept relevant and brief, and it is
important to note that the following is just an example of considerations for each system and not all
may require review.
General
Integument
Head/Neurologic
Eyes
Ears
Nose/Sinuses
Mouth/Pharynx
Neck
Chest/Lungs
Cardiovascular
Gastrointestinal
Urinary
Hepatic/Renal
Reproductive
Musculoskeletal
Endocrine
Source: Longe RL et al. Physical Assessment- A Guide for Evaluating Drug Therapy. Balitmore, MD: Lippincott Williams & Wilkins, 1994.Table 1.3, page 19 to 1-10.
Note that further targeted line of questioning may be necessary when a patient reports symptoms
or unveils an underlying condition. The following line of questioning can be used for further
symptom assessment.
Where is the symptom?
Location
What is the symptom like? Does it interfere with the patients
Quality Severity
Quantity
Timing
Setting
Modifying factors
Associated symptoms
Source: Giberson S, Stein E. Performing patient assessment: a pharmacy perspective. Pharmacy Times 2002;68(12):44-48..
(
)
x 0.85 if female
(
)
x 0.85 if female
Assumptions
The Cockcroft and Gault equation is used in the development of drug dosing adjustments
for patients with impaired renal function and therefore should be the primary equation
used when dose adjustments may be necessary2
This equation assumes a normal adult body weight and composition. This excludes
patients with amputations, elite athletes, neonates/children, catechetic patients or obese
patients.3
This equation also assumes serum creatinine is stable (steady state). This excludes acute
renal failure/injury, pregnant patients or patients with renal allografts (transplants).3
Some institutions use a multiplier of 80 (vs 88.4) due to laboratory standardization of
serum creatinine analysis. Using 88.4 can overestimate ClCr by 5-10%2
If patient bodyweight is available, can be used as a variable in the Cockcroft and Gault
equation to estimate creatinine clearance
Special Populations
Normal Renal Function
Underweight
Obese
Elderly
Patients with normal renal function usually do not require dosage adjustments. It is important to note that the Cockcroft and
Gault equation usually overestimates clearance in patients with normal renal function. The CKD-EPI equation has been shown
to estimate eGFR well in patients with normal renal function.4
In patients who are below their Ideal Body Weight (IBW), use actual weight in any calculations
In obese individuals the Cockcroft and Gault equation greatly overestimates renal function when total body weight (TBW) is
used. Lean body weight (LBW) can be substituted into the Cockcroft and Gault Equation to estimate ClCr.5 Or the SalazarCorcoran Equation developed for obese patients can also estimate ClCr.6 Also, always check the drug monograph to see if
specific dose recommendations are made for obese patients as some drugs have been studied.
9270 ()
9270 ()
LBW (kg) males = 6680+216 (2 )
LBW (kg) females = 8780+244 (2 )
Salazar-Corcoran Equation for estimating creatinine clearance in obesity:
Link to Calculator: http://www.globalrph.com/salazar.htm
The Cockcroft and Gault equation can underestimate renal function in the elderly due to the fact that this equation has a builtin propensity to make renal function worse with age. However, a conservative approach to drug dosing is warranted for this
patient population to minimize adverse drug events,7,8 therefore the use of the Cockcoft and Gault equation is acceptable.
Renal function estimation equations specific to children are used in practice. The most well-known equation is the Schwartz
equation9, but other newer equations have also been developed.10 Therefore adult equations should not be used for this
population to estimate renal function.
Link for Global RPh Calculator for multiple creatinine clearance methods (comparing different weight adjustments):
http://www.globalrph.com/multiple_crcl_2012.htm
Was developed for use primarily in diabetic patients with impaired renal function and chronic renal disease (ages 18-70 years)
Should NOT be used in patients with an estimated eGFR greater than 60mL/min/1.73m2 as it does not accurately predict eGFR in
patients with good renal function
Is standardized to a normal body surface area (BSA) of 1.73m2 can adjust based on patient specific BSA.
References
1.
2.
Cockcroft DW and Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41
Nyman HA, Dowling TC, Hudson JQ et al. Comparative Evaluation of the Cockcroft-Gault Equation and the Modification of Diet in Renal Disease (MDRD) Study Equation for Drug Dosing: An Opinion on the Nephrology Practice and
Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2011;31(11):1130-1144
3. Inker LA and Perrone RD. Assessment of Kidney Function. UpToDate. [Accessed December 9, 2013]
4. Stevens LA, Schmid CH, Greene T et al. Comparative Performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study Equations for Estimating GFR Levels Above 60 mL/min/1.73
m2. Am J Kidney Dis 2010:56:486-495.
5. Demirovic JA, Pai AB and Pai MP. Estimation of creatinine clearance in morbidly obese patients. Am J Health-Syst Pharm. 2009; 66:642-8
6. Salazar DE and Corcoran GB. Predicting creatinine clearance and renal drug clearance in obese patients from estimated fat-free body mass. Am J Med. 1988 Jun;84(6):1053-60
7. Flamant M, Hayman JP, Vidal-Petiot E et al. GFR Estimation Using the Cockcroft-Gault, MDRD Study, and CKD-EPI Equations in the Elderly. Am J Kidney Dis. 2012;60(5):847-849
8. Dowling T, Wang ES, Ferrucci L et al. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy
2013;33(9):912921
9. Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A: A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics 58:259-263, 1976
10. Hoste L, Dubourg L, Selistre et al. A new equation to estimate the glomerular filtration rate in children, adolescents and young adults. Nephrol. Dial. Transplant. (2013) doi: 10.1093/ndt/gft277
11. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130(6):46170
12. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, Van Lente F, Greene T, Coresh J. A New Equation to Estimate Glomerular Filtration Rate. Ann Intern Med. 2009; 150:604-612.
Warfarin
Insulin
Antipsychotics (atypical and typical)
Opioids
Benzodiazepines
Antiepileptics
Digoxin
Amiodarone
Lithium
Immunosuppressant agents
Methotrexate
The Institute for Safe Medication Practices also maintains a list of high-alert medications. Follow the
link here: http://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp
Effect
Reversible hearing loss
Reversible hearing loss (bilateral)
Reversible hearing loss
Reversible hearing loss
Irreversible hearing loss
Irreversible hearing loss
If you have a patient on one or more of these medications, ensure they have been having regular
hearing tests.
Quetiapine
Tricyclic antidepressants
Chloroquine/hydroxychloroquine
Digoxin
Indomethacin
Tamoxifen
Vigabatrin
Quinine
Ethambutol
Effect/Action
Require annual eye exam
Require eye exam every 6 months
May also experience reversible
cataracts, increased IOP
Cataracts
Increased IOP in high-risk patients
Irreversible retinopathy
Reversible vision disturbances
Reversible color disturbances
Retinotoxicity
Permanent decrease in visual acuity
Irreversible loss of peripheral vision
Permanent blurred vision or blindness
Decreased contrast sensitivity
Decreased color vision
IOP = Intraocular pressure; If you have a patient on one or more of these medications, ensure they
have been having regular eye exams.
Source: Amy Oliver 4th Year Elective Home Care Chart Review
Always remember that clinical practice guidelines are being constantly updated. To find the
latest guidelines or to find a guideline for a condition not listed here, follow this link:
Canadian Medical Association - Clinical Practice Guidelines Database:
http://www.cma.ca/clinicalresources/practiceguidelines
Lung Association Find a lung function testing lab or spirometry clinic in your area:
http://www.lung.ca/respDB/search-testing_e.php
Manitoba Comprehensive
Medication Review Toolkit
Case Examples
Case 1 - Elizabeth
You have scheduled a medication review with Elizabeth Martin, a patient of yours with asthma. Elizabeth was
recently hospitalized for an acute exacerbation of her condition. You have suggested a medication review to
her based on this fact, as well as because her frequency of salbutamol refills has steadily increased with 2
refills in the past month.
The date today is March 1, 2013. Your pharmacy assistant presents you with this demographic information:
Best Possible Medication History
1. Patient Information
Name
Age
Elizabeth Martin
Gender
Male
Female
23
Pharmacare
Family Physician
Dr. Cares Mountain Medical
Other Physician/Specialist
Undifferentiated
Address
City/Province
423 Anywhere St
Postal Code
X0X 0X0
Reason for Med Review
Winnipeg, MB
Phone #
(204) 555-2053
License No.
S. Robinson
123456
exacerbation
What is your primary concern about your medications today?
Patient is concerned about recent hospitalization and would like her breathing to
improve.
What are your expectations from your medications, and what would like to achieve from your med
review today?
She would like to be able to exercise without feeling short of breath. She does not
want to have to go to the hospital again.
Strength
Directions
Salbutamol
Salbutamol
Salbutamol
Salbutamol
Salbutamol
100 mcg
100 mcg
100 mcg
100 mcg
100 mcg
Fluticasone
Yasmin
Yasmin
Quantity
Dispensed
200 doses/MDI
200 doses/MDI
200 doses/MDI
200 doses/MDI
200 doses/MDI
Date refilled
Made
By
APO
APO
APO
APO
APO
14/02/2013
01/02/2013
10/01/2013
12/12/2012
15/11/2012
Refills
Remaining
1
2
3
4
5
250 mcg
1 puff BID
GSK
120 doses/MDI
15/11/2012
30mcg/3mg
30mcg/3mg
UD
UD
BPC
BPC
84
84
13/01/2013
15/11/2012
2
3
Elizabeth is waiting for you in the private patient counseling area. She has brought all of the medication she
has at home with her today.
Before the medication review can commence, it is necessary for the pharmacist to obtain consent to carry out
the review. The pharmacist describes the process as follows:
Elizabeth, today we have invited you in to the pharmacy for a comprehensive medication
review. I first want to let you know that everything we say here is private and confidential. I
know you have been recently hospitalized for your asthma and I am concerned you are not
getting the most out of your medications. During the review, we will look at each of your
medications one at a time and discuss them in detail. We want to be sure you have the most
benefit from the medication and minimize negative things like safety issues and side effects. I
also want to make sure you know what each of your medications is used for and how to use
them properly. These are important because we need you to be an active participant in
managing your asthma. We will also discuss the over-the-counter and natural health products
you may be taking in the same way. Do I have your consent to perform a medication review?
The pharmacist must also receive consent from the patient to share any information relevant to
Elizabeths medical care with other members of the health care team, such as her family physician or
specialist. The pharmacist says:
Elizabeth, in the event that we discover some issues with your medication today, I will need to
have your consent to communicate this information to Dr. Cares, your family physician and/or
Dr. Woods, your respirologist. We may need new prescriptions or different doses, or you may
need a follow-up appointment with another health care professional for reassessment. Do you
consent to me sharing this information in a confidential manner with other health care
professionals who are part of your health care team?
2. Consent
Patient has received information on, and has consented to review process
Patient Signature:__
Patient has agreed that information may be shared with their physician and other healthcare
providers
Patient Signature:__
Elizabeth Martin____________________________________
Having now received consent, the pharmacist may begin to collect applicable Health and Lifestyle
Information from Elizabeth. The pharmacist says:
To begin, I would like to ask you a few questions about your general health and lifestyle. These
questions are not meant to pry or be judgmental, but there are certain aspects of a patients
lifestyle that can affect their chronic conditions and medications.
3. Health Information and Lifestyle Factors
Inquiry
Allergies
Yes/No
Y N
Details/Comments
Reaction:
Seasonal allergies
Smoker
Is now a good time to quit?
Y N
Former Smoker
Alcohol Consumption
Y N
x_3_years
Drinks/week:
Caffeine Intake
Y N
Drinks/day: 2 cups/day
Grapefruit (Juice)
Consumption
Y N
Nutritious Diet
Y N
Restricted Diet
Y N
Physically Active
Cigarettes/day: 10/day
could do more
Minutes/week: 90 mins/week
Y N
Y N
Pneumococcal Immunization
(if over 65)
Other Vaccinations (travel,
routine, etc.)
Y N
Y N
Y N
Y N
Date/Result:
Height:
Weight:
Normal Overweight
Underweight
Y N
Other
Y N
The pharmacist continues by asking Elizabeth about her current medical conditions. Note that it is not
sufficient to just list the condition; it is essential to ask further targeted questions in order to assess the
control of that condition, symptoms, etc and whether or not further action is necessary.
4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters)
Kidney Disease? Liver Disease? BP = HR = RR =
CrCl =
1.
Asthma x 15 years
Y N NA Pregnant? Trimester:
Y N NA Breastfeeding?
2.
symptoms
for exacerbation
Head to toe Assessment regarding other complaints/concerns/bothersome symptoms:
Do any ever require self treatment?
Next, the pharmacist goes over each of Elizabeths medications with her one by one. This form is
revisited later when the pharmacist is analyzing the information to identify DTPs.
5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)
Medication
How Taken
Name, Strength
Dose, Route,
Frequency, Time
of Day, Special
Instructions
How
long
taken
Issues
Identified
Yes:
No:
Proceed
to DTP
Identifi
ed
Verify
to
continu
e as per
Additional
Comments
Salbutamol MDI
1-2 puffs
Asthma
15
100 mcg/inh
prn
Rescue inhaler
years
last 2 weeks
Fluticasone MDI
1 puff BID
Asthma
Patient is not
Controller Medication
months
currently using,
250 mcg
dislikes taste
Yasmin 28-day
1 tab daily
Oral contraceptive
7 years
Ibuprofen
Prn (OTC)
Occasional headaches,
11
menstrual cramps
years
no stomach pain
For cold/flu
Not
Last use 3
symptoms
known
months ago
4 years
400 mg tablets
Buckleys All-in-
Prn (OTC)
One
Cetirizine 10 mg
1 tab daily
Prn (OTC)
not regularly
Finally, the pharmacist asks Elizabeth about any medications that have been recently discontinued.
Once again, the Require Further Action section is left blank until after the session.
6. Recently Discontinued Medications
Medication
How Taken
Name, Strength
Dose, Frequency,
Time of Day,
Special Instructions
Purpose for
Use
Require
Further
Action?
1 inhalation
Asthma
Used x 15 y
Respirologist
turbuhaler
BID
controller
Stopped 3
switched to
months ago
Fluticasone MDI
Yes:
No:
Proceed
to DTPs
Identifi
ed
Verify
to
contin
ue as
per
At this point, the pharmacist has collected all the necessary information from Elizabeth. In order to
have time to review the information and do some more reading with regard to treatment guidelines
for asthma, the pharmacist asks Elizabeth to come back in 3 days to discuss the DTPs identified.
After review, the pharmacist completes the above charts as follows:
5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)
Medication
Name, Strength
How Taken
Dose, Route,
Frequency, Time
of Day, Special
Instructions
How long
taken
Salbutamol MDI
1-2 puffs
Asthma
15
100 mcg/inh
prn
Rescue inhaler
years
Fluticasone MDI
1 puff BID
Asthma
Controller Medication
months
250 mcg
Issues Identified
Yes:
No:
Additional
Comments
Yes
Yes
Patient is not
last 2 weeks
currently using,
dislikes taste
Yasmin 28-day
1 tab daily
Oral contraceptive
7 years
No
Ibuprofen
Prn (OTC)
Occasional headaches,
11
menstrual cramps
years
No
Not
No
Last use 3
Yes
400 mg tablets
Buckleys All-in-
Prn (OTC)
One
Cetirizine 10 mg
known
1 tab daily
Prn (OTC)
4 years
no stomach pain
months ago
not regularly
How Taken
Dose, Frequency,
Time of Day,
Special Instructions
Purpose for
Use
1 inhalation
Asthma
Used x 15 y
Respirologist
turbuhaler
BID
controller
Stopped 3
switched to
months ago
Fluticasone MDI
Require
Further
Action?
Yes:
No:
Yes
Using the form, the pharmacist must now list the DTPs identified for Elizabeth and prioritize them to
determine what to address first.
For those drug therapy problems above which can be corrected with immediate action and no further research
or consultation, document your plan below:
DTP
#
2
3
Proposed solution
Discussed
with
patient
Follow-up Plan
The care plan to address Elizabeths asthma control is much more complex, so the pharmacist employs the
Pharmacy Care Plan form.
Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug
coverage and non-pharmacological interventions.
Alternative #1:
Start fluticasone MDI 1 puff BID. Equally efficacious to budesonide, ICS will decrease
inflammation in the lung. Respirologist had previously prescribed this option. Plan to assess MDI
technique, may need to utilize an aerochamber to improve drug delivery and minimize the bad
taste Elizabeth was experiencing. Potential for oral candidiasis will be decreased with rinsing
mouth after each dose. Fluticasone (Flovent) listed under Part 1 of Pharmacare, aerochamber
will not be covered.
Alternative #2:
Re-start budesonide turbuhaler 1 inhalation BID. Patient had previous experience and success
with this medication, it still satisfies the requirement for an ICS. Budesonide is Part 1 of
Pharmacare, no need for an aerochamber with this option.
Monitoring:
To assess asthma control: < 4 doses of salbutamol/week, no symptoms with exercise, no further
hospitalizations, no missed work (after 2-3 weeks and ongoing). Assess adherence to regular
dosing of ICS after 1 week. Reassess for inhaler technique/patient satisfaction at each refill.
Candidate for peak flow meter. Planned date of follow-up: 1 week after implementation of plan
S. Robinson____________________
Pharmacist signature
March 1, 2013__
Date of Review
Having developed potential solutions to the DTPs identified as well as a care plan to resolve the DTPs
related to asthma control, the pharmacist discusses these issues with Elizabeth at their next meeting,
March 4, 2013.
The pharmacist begins by discussing the care plan developed to regain control of Elizabeths asthma.
The pharmacist re-educates Elizabeth about the importance of using the regularly scheduled ICS to
control underlying lung inflammation and minimize the need to employ the salbutamol inhaler.
Elizabeth understood that her recent hospitalization was likely due to her not using the fluticasone.
Next, the pharmacist outlines the treatment alternatives to Elizabeth so she could decide which she
would prefer. She expressed concern about the taste of the fluticasone spray, but was interested in the
potential use of an aerochamber to help her receive more of the medication with a more diffuse spray.
She tells the pharmacist that Dr. Woods, her respirologist, really wanted her to switch from
budesonide to fluticasone and she already has the fluticasone inhaler at home anyway. Ultimately,
Elizabeth and the pharmacist agree upon Alternative #1 above.
The pharmacist does a quick assessment of Elizabeths inhaler technique with the MDI and also
counsels her on how to use her new aerochamber. They then discuss the monitoring parameters based
on the care plan what Elizabeth needs to watch for and within what time frame.
The pharmacist turns their attention to the other DTPs identified during the medication review. As
each other DTP is addressed, the pharmacist updates the chart as follows:
DTP
#
2
Proposed solution
Discussed
with
patient
Follow-up Plan
Yes, not
Ongoing at refills
ready to
Provided pt with
quit
reading material
Yes,
Phone reminder
patient
mid-March when
agrees
Yes
The pharmacist informs Elizabeth that her physician will be made aware of the results of the
medication review for information purposes. The pharmacist also tells Elizabeth to expect a follow-up
call in about a week to discuss how the fluticasone inhaler has been working for her. Before Elizabeth
leaves, the pharmacist confirms that the contact information they have on file is up-to-date.
The pharmacist provides Elizabeth with an up-to-date medication list for her records.
As discussed, the pharmacist completes a Health Care Professional Communication Form to update the doctor about the medication review.
The DTPs identified, Pharmacy Care Plan and Medication List are also included. In this case, there is no action required from the prescriber,
but the pharmacist is communicating their findings to ensure all members of the health care team are well-informed about the patient.
Health Care Practitioner Communication Form
Date:_March 4, 2013__
Health Care Practitioner
PHIN
Dr. Cares
Elizabeth Martin
123456789
Address
Address
423 Anywhere St
City/Province
Postal Code
City/Province
Postal Code
Winnipeg, MB
Y1Y 1Y1
Winnipeg, MB
X0X 0X0
Pharmacist: S. Robinson
Phone #
Fax #
DOB
Phone#
(204) 555-6379
(204) 555-6378
14/01/1990
(204)555-2053
Dear Dr.___Cares_______,
Your patient had a Comprehensive Medication Review completed on __March 1/13___. 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 dont hesitate to contact me.
Drug Therapy Problem
Patient wasnt using fluticasone
inhaler due to unpleasant taste.
Pharmacist Recommendation
Information Only
Prescriber Comments/Revisions
Action Required
Yes
No
Yes
No
License #: 123456
Make Changes as
Recommended
Action Required
Prescriber Signature:
License #:
Date:
The pharmacist follows up with Elizabeth in 1 week to check in about her inhaler use and the aerochamber as well as improvement of
asthma symptoms. The pharmacist also calls her in about 3 weeks to remind her about taking a daily antihistamine to prevent seasonal
allergy symptoms. The Patient Follow-up Form is completed as follows:
Results
fluticasone inhaler,
needs improvement
of asthma symptoms
feeling better
Any new concerns?
salbutamol
cetirizine 10 mg daily,
seasonal allergies
starting tomorrow
Any new concerns?
Case 2 Steve
On December 28 2012, you completed a comprehensive medication review with Steve Wilkinson. Steve is a
regular client at your pharmacy and is planning to go to Arizona for a few months in the New Year. Steves
physician referred him for a medication review to ensure that all of his medications are in order before going
away.
The completed forms from the initial comprehensive medication review appointment are shown below. For
more detail on collecting background information during the initial appointment, please see Case 1
Elizabeth.
Best Possible Medication History
1. Patient Information
Name
Age
Steve Wilkinson
Gender
Male
Female
72
Undifferentiated
Address
City/Province
Winnipeg, MB
Phone #
X0X 0X0
Reason for Med Review
(204) 555-5555
Phone #
999000
Steve is concerned about having all medications and vaccinations up to date before
leaving for Arizona.
What are your expectations from your medications, and what would like to achieve from your med
review today?
He would like to understand what all of his medications are used for, and make
sure he is using everything correctly for his conditions.
Strength
Directions
Sulfamethoxazole/ 800/160mg
Trimethoprim
Latanoprost
0.005%
Tamsulosin
Ramipril
Metoprolol
0.4mg
5mg
25mg
Atorvastatin
Clopidogrel
20mg
75mg
2 tablets
twice daily
for 3 days
1 drop in
each eye at
bedtime
1 cap daily
1 cap daily
1 tablet twice
daily
1 tablet daily
1 tablet daily
Made
By
APO
Quantity
Dispensed
12 tablets
Date refilled
22/12/2012
Refills
Remaining
0
CO
1 bottle
16/12/2012
RAT
APO
APO
60 caps
90 caps
180 tablets
16/12/2012
08/12/2012
08/12/2012
3
2
2
APO
APO
90 tablets
90 tablets
08/12/2012
08/12/2012
2
2
2. Consent
Patient has received information on, and has consented to review process
Patient Signature:__
Patient has agreed that information may be shared with their physician and other healthcare
providers
Patient Signature:__
Steve Wilkinson____________________________________
Yes/No
Y N
Details/Comments
Reaction:
Penicillin
Hives
Codeine
Stomach Pain
Smoker
Is now a good time to quit?
Y N
Former Smoker
Alcohol Consumption
Y N
Drinks/week:
Caffeine Intake
Y N
Drinks/day: 3
Grapefruit (Juice)
Consumption
Y N
Nutritious Diet
Y N
Restricted Diet
Y N
Physically Active
x_10_years
Y N
Y N
Pneumococcal Immunization
(if over 65)
Other Vaccinations (travel,
Y N
Y N
Please list:
Y N
When:
Y N
Y N
Date/Result:
Height:
Weight:
Normal Overweight
Underweight
Y N
Other
4. Medical Conditions (List medical conditions in numbered spaces with relevant information/parameters)
Kidney Disease? Liver Disease? BP = 137/84
CrCl =
1.
Hypertension
2.
HR =
RR =
High cholesterol
at home monitor
levels
5.
Hx of MI
Y N NA Pregnant? Trimester:
Y N NA Breastfeeding?
3.
BPH
4.
Glaucoma
6.
7.
8.
10.
11.
12.
-2010
9.
Difficulty sleeping developing over past few years, getting worse in last couple months and has started using diphenhydramine to
try and resolve, takes 1-2 hours to fall asleep and wakes up frequently, feels tired throughout day and naps in afternoon, 2 cups
coffee in morning and 1 in afternoon, usually has nighttime snack, goes to bed at 9-10pm
Urinary Symptoms has been increasingly difficult to go to the bathroom, burning while he pees, recently treated for a UTI with
TMP/SMX
Family History
Cancer
How Taken
Name, Strength
Ramipril 5 mg
Metoprolol 25mg
breakfast
heart
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Additional
Comments
3 years
no
HTN, post-MI
protect heart
2 years
no
Post-MI
lower cholesterol
3 years
yes
Drinks GF juice
Clopidogrel 75mg
thin blood
2 years
yes
Post-MI
3 years
no
Buys OTC
breakfast
heart
Glaucoma
5 years
no
breakfast
ASA 81mg
Latanoprost 0.005%
bedtime
Tamsulosin 0.4mg
BPH
4 years
no
Diphenhydramine 50mg
1 cap at bedtime
Sleep disorder
1-2 months
yes
Vitamin E 800IU
Mens Multivitamin
Supplement, keep
1 year
yes
breakfast
heart healthy
Supplement
5 years
no
Buys OTC
PRN
no
Buys OTC
breakfast
Acetaminophen 325mg
PRN
As of January 3, 2013 the pharmacist has reviewed the information from the initial appointment with Steve
and met to discuss the identified DTPs and solutions which are outlined below. With Steves agreement to
these proposed solutions, the Drug Therapy Problems Identified form is updated, a Pharmacy Care Plan is
made, and a Health Care Practitioner Communication form is sent to Steves family physician along with the
care plan and medication history.
In addition to reviewing these DTPs, the pharmacist ensures that Steves primary concerns at the initial
appointment are addressed including reassurance that there are no specific vaccinations required for travel to
Arizona and that each medication has been reviewed for his understanding.
without a
valid indication.
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
Follow-up Plan
#
with
patient
2
yes
None- patient
agrees to avoid GF
consumption
yes
None- patient
agrees to stop
taking vitamin E
yes
Update pharmacy
profile
yes
Direct to local
vaccination clinics
Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence, cost, drug
coverage and non-pharmacological interventions.
Alternative #1: Steve should stop using diphenhydramine to help him sleep due to the
anticholinergic side effects that may be causing urinary problems, including urinary tract
infections. This medication is also concerning for use in those with glaucoma and is a drug that
is deemed not appropriate for use in the elderly by Beers criteria. Steve should instead try
Zopiclone at an initial dose of 3.75mg to be taken at bedtime as needed which can be tapered
up every 1-2 weeks if needed to a maximum dose of 15mg. Zopiclone is the drug of choice for
the elderly population as it has a short half life of 5 hours, convenient dosing just prior to
bedtime due to its quick onset, and it may have less tolerance and withdrawal than other
insomnia medications making it ideal for long term management. Zopiclone does not interact
with Steves current drug regimen, it costs around $0.23/half tab of 7.5mg (3.75mg) and is
covered under part one of pharmacare.. Steve will also receive information on better sleep
hygiene to compliment this therapy.
Monitoring: Steve should experience decreased time to fall asleep to less than 1-2 hours,
decreased frequency of awakenings, and increased overall duration of sleep which he should
notice in 7-10 days with maximal benefits in 2-4 weeks. He should monitor for side effects
including agitation and anxiety, anterograde amnesia, confusion, signs of dependence, and any
impact on his daily functioning.
Planned date of follow-up: 1-2 weeks after initiation with zopiclone therapy.
__ MAnderson
Pharmacist signature
After a response is received from Steves family physician on January 8, 2013, a follow-up
appointment with Steve is conducted and recorded to counsel him on the proper use of his
new medication zopiclone as well as educate him on changes he can make to his sleep
behavior patterns to improve his sleep cycle. Steve is given an up-to-date medication history
form and a Patient Action Plan to help him remember everything discussed during the
medication review. These forms mentioned, as well as subsequent follow-ups, are shown
below to conclude Steves case.
Date:_January 3, 2012__
Health Care Practitioner
Dr. AlexJohnson
Steve Wilkinson
Address
Address
PHIN
123456789
City/Province
Postal Code
City/Province
Postal Code
Winnipeg, MB
Y1Y 1Y1
Winnipeg, MB
X0X 0X0
Pharmacist: M. Anderson
Phone #
Fax #
DOB
Phone#
(204) 555-1111
(204) 555-2222
23/05/1971
(204)555-5555
Dear Dr.___Johnson_______,
Your patient had a Comprehensive Medication Review completed on __December 28/12___. 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 dont hesitate to contact
me.
Drug Therapy Problem
Steve is experiencing urinary
problems due to diphenhydramine
use and a history of BPH, and
requires appropriate therapy for
sleep difficulty.
Pharmacist Recommendation
Information Only
Prescriber Comments/Revisions
Action Required
Yes
No
Yes
No
Mitte: 30 (thirty)
Sig: Take 1 tablet by mouth at bedtime
Refills:2
Discontinue diphenhydramine
Information Only
License #: 999000
Make Changes as
Recommended
Action Required
4.
I will get my pneumococcal vaccination
5.
I will stop taking vitamin E
6.
I will talk to the doctor about codeine allergy
How Taken
Name, Strength
Ramipril 5 mg
Metoprolol 25mg
breakfast
heart
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Additional
Comments
3 years
no
HTN, post-MI
protect heart
2 years
no
Post-MI
lower cholesterol
3 years
no
Clopidogrel 75mg
thin blood
2 years
no
Post-MI
3 years
no
Buys OTC
breakfast
heart
Glaucoma
5 years
no
breakfast
ASA 81mg
Latanoprost 0.005%
bedtime
Tamsulosin 0.4mg
BPH
4 years
no
Mens Multivitamin
Supplement
5 years
no
Buys OTC
breakfast
Acetaminophen 325mg
PRN
PRN
no
Buys OTC
Zopiclone
1 tab at bedtime
Sleep disorder
new
no
Follow-up required
Results
counseling on initiation of
sleep hygiene.
sleep hygiene.
Any new concerns?
pattern.
night.
Any new concerns?
improvement in sleep
dose.