Improvepolypharmacy.yale.edu



IMPROVE Pre-Clinic Chart ReviewID: Age:Labs:VS: Serum Cr: Liver disease? Y/NBP ranges:Pulse ranges:Calculated CrCl (HYPERLINK ""Calculatora):Height:Weight:Vit D:B12:A1C:TSH:Other pertinent labs (e.g., INR if on warfarin, etc.):Pharmacy Info (if known):Other pharmacies and providers?Strategies for med management (pill box?):Allergies/Adverse drug reactions:Is refill history up to date/pt taking meds? Y/NAre there recently expired meds? Y/NComplete the table (example on back):DiagnosesMedicationsNotes1. 2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.26.27.28.SAMPLEDiagnosesMedicationsNotesDiabetes mellitus1. Metformin 1000 mg po bidmax dose for renal function is: …2. Glargine 20 units SC qhs-spouse administers due to osteoarthritis Hypertension3. Lisinopril 5 mg po daily-K normal4. HCTZ 10 mg po daily-polyuriaHeart Failure5. Furosemide 40 mg po daily-EF 30%6. Digoxin 250 mcg po daily-unable to tolerate beta blocker-above Beers criteria doseObstructive sleep apnea7. n/a-does not wear CPAPErectile dysfunction8. Horny goat weed supplement-drug drug interaction with…Etc. ................
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