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Medication Therapy Management Assessment Tool Demographics:Patient ID#: Patient Name: Medical Record #:Date of Birth: Date of Assessment:Source(s) for Information:Medication List including OTC and Supplements: Name:Dose: Route: Frequency:Medication Management: Discrepancies noted from last discharge summary or PCP med list:Ability to prepare and take all oral and parenteral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals:( ) Able to independently take the correct oral medications and proper dosages at the correct times( ) Able to take medications at the correct times if individual dosages are prepared in advance by another person; or another person develops drug diary or chart( ) Able to take medications at the correct times if given reminders by another person at the appropriate time ( ) Unable to take medications unless administered by another personGeriatric Pharmacy Consult Medication ReviewDirect Patient Observation: Initial AssessmentDid patient present with a cane/walker/wheelchair???( ) Yes( ) NoIf Yes:( ) Cane( ) Walker( ) WheelchairDoes the patient usually wear glasses?( ) Yes( ) NoDoes the patient use hearing Aids?( ) Yes( ) NoMedication ADLs: Does the patient have their medications available? ( ) Yes( ) NoDo they have a medication list/card? ( ) Yes( ) NoIs the medication list/card up‐to‐date?( ) Yes( ) NoDo they have a medication list/card on them at all times? ( ) Yes( ) NoHave the patient describe how they take their medications:Do they use a pillbox? ( ) Yes( ) NoDo they keep meds in original bottles?( ) Yes( ) NoDo they receive help in taking medications? ( ) VNA( ) HBPC( ) Aid( ) Spouse( ) Child( ) Other; Describe: ____________Do they order their own refills?( ) Yes( ) NoHow do they refill their medications? ( ) Mail ( ) Phone( ) In person ( ) OtherDo they require reminders to take medications? ( ) Yes( ) NoWhere in their house do they keep their medications?What pharmacy do they primarily use? Do they use other pharmacies or mail order? ( ) Yes( ) Noa) If so, where?? ?b) If so, for what medications/reasons?Can they read the label on a medication bottle? ( ) Yes( ) NoCan they open a medication bottle with safety caps? ( ) Yes( ) NoMedication Reconciliation:Compare medication regimen (what is documented in chart vs. what patient explains or provides in clinic; include medication refill history evaluation)Discrepancies (i.e. change in dose, frequency, product)??( ) Yes( ) NoMedication Adherence, Safety and Adverse Effects:Are there young children in the household?( ) Yes( ) NoDoes the patient have trouble refilling medication on time?( ) Yes( ) NoIn the past week, how many doses of medications have they missed???( ) Never miss a dose/rarely miss a dose( ) Miss a once a week/occasionally miss a dose( ) Miss a dose once a day/often miss a dose( ) Miss a few doses every day/miss a lot of dosesWhat do they do if you miss a dose? ( ) Take when I remember??( ) Double next dose??( ) Skip dose( ) Don’t knowHave they experienced any side effects from any medications?( ) Yes( ) NoIf Yes:a) When does it occur?b) how long?c) What did you do about it?View on Number of Medications: Ask Do you think the number of medications that you are currently taking is:??( ) About right( ) Too many( ) Not enough( ) Don't knowMost Important Medication: If I were to stop all of your medications today except for one, whichone would you not let me stop?( ) I don’t Know ( ) Or, Name of Medication: Why?( ) It works well( ) It helps with symptoms( ) It will make me live longer( ) My doctor told me to take it( ) Will prevent complications or disease long‐term( ) Other: Least Important Medication: If you had to stop one of your medications, which medication wouldyou stop? ( ) I don’t Know ( ) Or, Name of Medication: Why?( ) Side effects( ) It is complicated to take( ) It is not effective( ) Cost( ) Don't understand what it's for( ) Condition that is it used for is no longer bothersome( ) Other:Non‐Prescription Medication Comprehensive Review?? Head, Eyes, Ears, Nose and Throat:Do you take any medications for headaches, like:??( ) Tylenol (acetaminophen)( ) Advil/Motrin (ibuprofen)( ) Exedrin( ) Aleve (naproxen)( ) Bayer/St. Joseph/Bufferin/Ecotrin (aspirin)Do you take any medications for dry, itchy, or red eyes, like:( ) Visine( ) Clear Eyes ( ) Renu( ) Alcon( ) OptiFreeReplish( ) AMO ( ) Complete Moisture PlusDo you take any medications for your nose or for sinus conditions, like:( ) Sudafed( ) Benadryl (diphenhydramine)( ) Afrin/Dristan (oxymetazoline)( ) Zicam( ) Saline Spray( ) Claritin/D( ) Zyrtec( ) Primatene Mist( ) Alavert( ) Mucinex( ) Theraflu( ) Coricidin HBPDo you take any medications for cough or sore throat, like:( ) Nyquil/Dayquil( ) Robitussin( ) Delsym( ) Mucinex( ) Vick’s Vapor rub( ) Chloraseptic spray( ) Lozenges/Cough drops( ) DimetappDo you take any medications for dizziness, like:( ) Antivert/Bonine (meclizine)( ) Scopolamine( ) DramamimeDo you take any medications for fatigue or to help you stay awake, like:( ) No Doz/Vivarin (caffeine)Do you take any medications for sleep, like:( ) Compoze/Simply Sleep( ) Nytol/Unisom( ) Benadryl (diphenhydramine)( ) Tylenol PM( ) Melatonin( ) Exedrin PM( ) Advil PM( ) Goody’s PMGastrointestinal/Bladder Issues:Do you take any medications for Nausea/Vomiting, like:( ) Antivert/Bonine (meclizine)( ) Scopolamine( ) Dramamine( ) Phillips (milk of magnesia)( ) Gas‐X( ) Mylanta( ) Pepto Bismol/Kaopectate (bismuth)Do you take any medications for Heart burn/ Indigestion, like:( ) Tums( ) Prilosec (omeprazole)( ) Alka Seltzer( ) Mylanta( ) Maalox Rolaids( ) Alamag( ) Caltrate( ) Zantac (ranitidine)( ) Milk of Magnesia( ) Pepcid (famotadine)( ) Tagamet (cimetidine)Do you take any medications for diarrhea, like:??( ) Imodium (loperamide)( ) Pepto Bismol/Kaopectate (bismuth)Do you take any medications for constipation, like:( ) Metamucil (psyllium)( ) Senna/S( ) Colace (docusate)( ) Dulcolax (bisacodyl)( ) Citrucel Fibercon( ) Fleet( ) Miralax( ) Mineral Oil( ) Benefiber( ) Fiber Choice( ) Ex LaxPain:Do you take any medications for Pain, like:( ) Tylenol (acetaminophen)( ) Advil/Motrin (ibuprofen)( ) Exedrin( ) Aspirin( ) Aleve (Naproxen)( ) Icy Hot( ) Bengay( ) Capsacin( ) GlucosamineIf pain, where does it hurt?On a scale of 0 to 10 with ten being the worst pain imaginable, how would you rate your pain???________________Topicals (Circle all that apply):Do you use any creams, lotions, ointments, or shampoos, like:( ) Tigerbalm( ) Capsacin( ) Bengay( ) Hydrocortisone( ) Selsun Blue( ) Coal tarMedication Fall Risk ReviewRisk Factors: Taking more than four medicationsPsychotropic drugs:Benzodiazepines (Diazepam, clonazepam, lorazepam)Sedatives: “Zs” (Zopiclone, zolpidem)Sedating Antidepressants: Tricyclics and related (Amitriptyline, imipramine, nortriptyline, trazodone)MAOIs: (Phenelzine, Isocarboxazid, Tranylcypromine)AntipsychoticsSSRIs/SNRIsOpioidsAntiepileptics (phenytoin, carbamazepine, phenobarbital, valproic acid, gabapentin)Muscle Relaxants (baclofen, dantrolene)Sedating antihistamines (diphenhydramine, chlorpheniramine, hydroxyzine)Anticholinergics that act on the bladder (oxybutynin, solifenacin, tolterodine)Cardiovascular meds:Alpha receptor blockers (doxazosin, terazosin)Centrally acting alpha agonists (clonidine)Diuretics (thiazides, loop)Vasodilators (hydralazine)Acetylcholinesterase inhibitors (donepezil)Narrative Summary:Adapted from: “Geriatric Consult Clinic Medication Review,” by Sean M. Jeffery, PharmD, CGP, FASCP, FNAP, AGSFSchool of Pharmacy, University of ConnecticutPermission required for distribution ................
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