MTM Pre-Seminar Exercise Materials_2

PreSeminarExerciseInstructions Participation in the live seminar component of Delivering Medication Therapy

Management Services requires completion of a pre-seminar exercise. Participants must complete two patient cases. For the first case, participants should interview one patient with three or more

chronic conditions AND five or more medications. The documentation listed below will need to be completed for this case (forms can be found on subsequent pages):

Authorization for Medication Review

o The Authorization form should not be turned in. o This is intended to cover the pharmacists involvement with the patient

from a liability standpoint as well as to inform the patient about his or her involvement with the medication review.

Patient History Form (to be filled out by the patient as part of the information

gathering process.) Medication Therapy Review (MTR)

The second case for participants to accomplish involves the standardized case

(patient Toni). The documentation listed below need to be completed for this case: Medication-Related Problem Prioritization List Personal Medication Record (PMR) Medication-Related Action Plan (MAP) SOAP Note

Friends, family, and/or other patients with whom the pharmacist feels comfortable are all appropriate candidates for this activity. The pharmacist should explain to the patient that the interview and documentation is for educational purposes only, and the patients identity will remain confidential. To maintain patient privacy, participants need to ensure that no patient identifying information is included on the documentation.

Participants should bring all completed forms to the live seminar because these

will be required for admittance. Participants should be prepared to use these patient cases during interactive portions

of the live seminar.

PreSeminarExerciseToni

Toni is a 46-year-old African American female patient. She was diagnosed with diabetes approximately 1 year ago and began glipizide XL 10 mg daily. The diagnosis frightened her, so she lost 5 lb, adhered to her medication regimen, and educated herself about diabetes. She returned to her doctor 6 months ago. Her physician said that her numbers had improved, but she still was well outside her therapeutic range, so the physician increased her glipizide XL to 10 mg twice daily. Toni saw your MTM brochure at the clinic and made an appointment for a medication therapy review today (9/1/08). Here is the pharmacys record of her medications: Medication Sig # Original Fill Last Fill HCTZ/Triamterene 25 mg/37.5 mg 1 daily 30 6/28/02 8/10/08 Felodipine 5 mg 1 daily 30 11/22/04 8/10/08 Simvastatin 20 mg 1 at bedtime 30 11/3/04 12/1/07 Simvastatin 40 mg 1 at bedtime 30 1/6/08 8/2/08 Glipizide XL 10 mg 1 daily 30 9/10/07 2/6/08 Glipizide XL 10 mg 1 twice daily 60 3/6/08 8/10/08 Ibuprofen 400 mg As needed 30 7/16/04 4/21/08 She has filled out a Patient Information Form (attached). During the patient interview, you discover the following: SH: Very sedentary at work. Watches TV several hours each night. Snacks throughout the day and evening while working and watching TV. She smokes about 10 cigarettes a day. A knee replacement 2 years ago has limited her physical activity. ROS: c/o fatigue and frequent urination. She gets up two to three times a night to go to the bathroom. She reports no episodes of hypoglycemia. PE: BP 142/88 HR 78 RR 18 Weight is 250 lb. After an initial weight loss, she became frustrated and has gained 10 lb over the past year. Monofilament test indicates good sensation in both feet. Laboratory Results (point-of-care testing last month): Glucose A1C 9% FBG 240 mg/dL LFTs AST 40 Units/L ALT 35 Units/L

Cholesterol (fasting) TC 210 mg/dL HDL 30 mg/dL TRG 300 mg/dL LDL 120 mg/dL

Patient Name: TONI xxxxxxxxxxxPatient Identifier: 99-09999

Page 1 of 2

PATIENT INFORMATION FORM Please complete the following information in preparation for your medication review. Shaded boxes are for pharmacist use. Date: 9/1/11

Address: 231 Green Ave Date of Birth: 10/31/65 Age: 46

City, State, Zip: Garland, TX Sex M ;F Phone: 972-555-2525 Race: White ;Black Cell: 972-330-2525 Asian Hispanic E-mail: [email protected] Native American Other______ Height: 5'8"______ Weight: 250 lb______

Medication Allergies: Reaction:

Codeine Upset stomach_________________________

SOCIAL HISTORY

Marital Status: Single Married Partnered Separated ;Divorced Widowed

Exercise: 0 minutes 0 times per week

Caffeine: 5 cups/day

Alcohol: 14 drinks/week

Tobacco: ____1/2_____packs/day for ___10______years

;Current Past Never Illicit drugs: none

Occupation: Customer Service Representative

FAMILY HISTORY

;Cancer ;Depression Other:___________

;Diabetes ;Heart attack

;High cholesterol ;Kidney disease

;High blood pressure

;Stroke

PAST MEDICAL HISTORY

Asthma ;Anxiety COPD ;Diabetes ;Depression

Cancer Heart attack Cancer Stroke Irregular heartbeat (atrial fibrillation)

;High cholesterol ;High blood pressure

;Difficulty sleeping GERD (acid reflux)

Ulcers (stomach/intestine)

Thyroid disease Other___________

HIPAA Note Certain information

blacked out to conceal protected health information.

Patient Name: TONI xxxxxxxxxxx Patient Identifier: 99-09999

Page 2 of 2

PAST SURGICAL HISTORY

Appendectomy CABG (bypass surgery) Hip replacement

Hysterectomy ;Knee replacement Pacemaker/defibrillator

Angioplasty (balloon surgery or stent)

;Live births #_____3_______ Other:___________________

CURRENT MEDICATIONS (include all medicines: prescribed, over-the-counter, vitamins, herbal medicines)

Name and strength of your medicine?

How do you take it?

For how long?

What is it for? Doctor

HCTZ 25 mg/ Triamterene 37.5 mg

1 daily 6 years Blood pressure Cartman

Felodipine 5 mg 1 daily 4years Blood pressure Cartman

Simvastatin 40 mg 1 at bedtime 4 years Cholesterol Cartman

Glipizide XL 10 mg 2 times a day 1 year Diabetes Singh

Ibuprofen 400 mg As needed 4 years Pain Lucas

Chromium 1 daily 1 year Diabetes

Magnesium 1 daily 1 year Diabetes

Multivitamin 1 daily 1 year Tired

Ranitidine 75 mg 2 times a day 4 years Stomach

EnochTypewritten Text

MEDICATIONRELATEDPROBLEMPRIORITIZATIONLIST

Medication-Related Problem Details Priority (Low, Medium, High)


MYMEDICATIONRECORDName:_____________________________________________Birthdate:____________________________Includeallofyourmedicationsonthisrecord:prescriptionmedications,nonprescriptionmedications,herbalproducts,andotherdietarysupplements.Alwayscarryyourmedicationrecordwithyouandshowittoallyourdoctors,pharmacists,andotherhealthcareproviders.

DrugTakefor WhendoItakeit? StartDate StopDate Doctor SpecialInstructions

Name Dose

ThissamplePersonalMedicationRecord(PMR)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,thePMRortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,thePMRisnotasubstituteforobtainingprofessionalhealthcareadviceortreatment.ThisPMRmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociationofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDS.

MYMEDICATIONRELATEDACTIONPLAN

Patient: Doctor(Phone): Pharmacy/Pharmacist(Phone): DatePrepared:

ThelistbelowhasimportantActionStepstohelpyougetthemostfromyourmedications.FollowthechecklisttohelpyouworkwithyourpharmacistanddoctortomanageyourmedicationsAND

makenotesofyouractionsnexttoeachitemonyourlist.

ActionstepsWhatIneedtodo NotesWhatIdidandwhenIdidit.

MyNextAppointmentwithMyPharmacistison:______________(date)at_________AMPMThissampleMedicationRelatedActionPlan(MAP)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,theMAPortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,theMAPisnotasubstituteforobtainingprofessionalhealthcareadviceortreatment.ThisMAPmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociation

ofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDSFoundation.

MedicationTherapyReviewSOAPNotesForm

Patient Name:

Patient ID: Insurance Company:

Date of Birth: Age:

Sex: Evaluation Date: Subjective (what the patient tells you):

Objective (information you gather from physical exam, labs): Assessment (problems you found, from most important to least important): Plan (what interventions will be initiated for each problem):

Adapted from: Joseph Ineck, PharmD Creighton University Medical Center 1

PatientHealthandHistoryReviewName:______________________________Date:______________DOB:______________

Sex(circleone):MF MaritalStatus:_________________________

TelephoneNumber(s)Home:___________________Work:_______________________

HomeAddress:______________________________________________________________

Street:_____________________________________________________________________

City:__________________________ State:____________ ZIP:_________________

Whoisyourprimarycarephysician?_____________________________________________

Whenwasyourlastcompletecheckup?__________________________________________

FamilyHistory(mother,father,brother,sister,grandparents)

Highbloodpressure Diabetes HighcholesterolHeartattack Stroke KidneydiseaseDepression Cancer Other:__________________

PastMedicalHistory PastSurgicalHistory

Asthma Highbloodpressure AppendectomyIrregularheartbeat(atrialfibrillation)

Heartattack Angioplasty(balloonsurgery)orstent

Anxiety Insomnia(difficultysleeping)

CABG(bypasssurgery)Hipreplacement

COPD GERD(acidreflux) HysterectomyDiabetes Ulcers(stomach/intestine) KneereplacementDepression Thyroiddisease Pacemaker/defibrillatorHighcholesterol Stroke Livebirths#__________Cancer Other:_______________ Other:__________________Allergies(includemedicationandfood):_____________________________________________________________________________________________________________________Intolerances(includesideeffectsfrompreviousmedications,suchasnausea,constipation,sleepiness,dizziness,stomachupset,etc.):______________________________________________________________________________________________________________________________________________________________________________________________


EnochTypewritten TextAvelina Espinas


EnochTypewritten Text02/06/30

EnochTypewritten TextMarried

EnochTypewritten Text905-387-8339

EnochTypewritten Text196 Solomon Cr.

EnochTypewritten TextSolomon Cr.

EnochTypewritten TextHamilton

EnochTypewritten TextOntario

EnochTypewritten TextL8W 2G7

EnochTypewritten TextAnastacio

EnochTypewritten TextApril 20, 2013

EnochTypewritten Textx





EnochTypewritten TextOsteoporosis



EnochTypewritten Text5


EnochTypewritten Textn/a

EnochTypewritten Textconstpation, stomach aches


CurrentSymptomReview:

Ifyouareexperiencinganysymptomsfromthefollowinglist,circleallthatapply.Ifnosymptoms,checknone.

Constitutional:

Weightloss Nightsweats ()NoneWeightgain Fatigue

HEENT:Visionproblems Doublevision ()NoneGlaucoma Cataracts Hearingproblems Ringingintheears ()NoneEaraches SensationofroomspinningOther:______________________ Nasalcongestion Nasaldischarge ()NoneNosebleeds Infection Other:______________________ Problemsswallowing Hoarsevoice ()NoneSoremouthorthroat Bleedinggums Other:______________________

Endocrine:Swollenglands Thyroidproblems ()NoneDiabetes Other:______________________

Respiratory:Cough Shortnessofbreath ()NoneSputum Wheezing Cigarettesmoking Other:______________________

Cardiac:Heartpain Highbloodpressure ()NoneHeartirregularity Palpitations Swellinginthelegs DifficultybreathingwhenlyingflatOther:______________________

Gastrointestinal:Constipation Reflux ()NoneHeartburn StomachorintestinalulcerHepatitis Nauseaand/orvomiting Other:______________________

Genitourinary:Frequency Burningwithurination ()NoneBloodinurine DifficultyholdingorcontrollingurineOther:______________________

Musculoskeletal:Jointaches Muscleweakness ()None













EnochTypewritten Text"shakey"



EnochTypewritten Textdiarhhea




Legweakness Musclecramps Other:______________________

Neurology:Headache Migraine ()NoneSeizure Numbness Tremors Fainting Other:______________________

Heme/Lymph:Bleeding Bloodclots ()NoneSwollenglands Other:______________________

Immuno:Allergies Rash ()NoneInfections Other:______________________

Psych:Depression Cryingspells ()NoneAnxiety Sleeping Sleepdisturbance Other:______________________

SocialSituation:

Withwhomdoyoulive?_______________________________________________________Areyoucurrentlyemployed?(circleone): YES NONameofemployer:____________________Position:_____________________________Doyoupresentlysmokecigarettesorusetobaccoinanyform?(circleone): YES NO Ifyes,howmanypacksdoyousmokeaday?__________Didyoueversmokecigarettesorusetobaccoinanyform?(circleone): YES NO Ifyes,howmanypacksdidyousmokeaday?__________ Forhowmanyyears?________ Whendidyouquit?_________Doyoudrinkalcoholicbeverages?(circleone): YES NO Ifyes,whatisyourusualconsumption(numberofdrinks)_____

ina(circleone):DAYWEEKMONTHDidyoueverdrinkalcoholicbeverages?(circleone): YES NO Ifyes,whatwasyourusualconsumption(numberofdrinks)_____

ina(circleone):DAYWEEKMONTH Forhowmanyyears?________ Whendidyouquit?_________Howmuchphysicalactivitydoyouperformperweek?_______________________________________________________________________





EnochTypewritten TextImmediate family










EnochTypewritten Text 1h a week; walking around neigbourhood




ImmunizationsWhendidyoulastreceivethefollowingimmunizations?Influenza ___________Tetanus/diphtheria/pertussis ___________Herpeszoster ___________ Pneumoccal ___________OtherWhatquestionsdoyouhaveaboutyourmedications?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatconcernsdoyouhaveaboutyourhealthandmedicalconditions?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatdoyouhopetogetoutofyourvisit?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EnochTypewritten Textnone


EnochTypewritten Textscared of heart attack or stroke.

EnochTypewritten Textsecurity, more information, awareness of coditions and what I'm on; interactions

MYMEDICATIONRECORDName:_____________________________________________Birthdate:____________________________Includeallofyourmedicationsonthisrecord:prescriptionmedications,nonprescriptionmedications,herbalproducts,andotherdietarysupplements.Alwayscarryyourmedicationrecordwithyouandshowittoallyourdoctors,pharmacists,andotherhealthcareproviders.

DrugTakefor WhendoItakeit? StartDate StopDate Doctor SpecialInstructions

Name Dose

ThissamplePersonalMedicationRecord(PMR)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,thePMRortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,thePMRisnotasubstituteforobtainingprofessionalhealthcareadviceortreatment.ThisPMRmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociationofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDS.

EnochTypewritten TextTelmasartan

EnochTypewritten Text40 mg

EnochTypewritten Text1 PO daily

EnochTypewritten TextCrestor


EnochTypewritten Textheart

EnochTypewritten Textblood pressure

EnochTypewritten Textdocusate sodium

EnochTypewritten TextAspirin



EnochTypewritten Textheart


EnochTypewritten Textconstipation

EnochTypewritten Text1 PO QD

EnochTypewritten Text1 QD

EnochTypewritten TextActonel


EnochTypewritten Textbone


EnochTypewritten Text1 Q week

EnochTypewritten Text1 Q day

EnochTypewritten TextAnastacio

EnochTypewritten Text"




EnochTypewritten TextVitamin B12




EnochTypewritten Text1000 mcg

EnochTypewritten Textneed it

EnochTypewritten Text1 PO daily


MEDICATIONRELATEDPROBLEMPRIORITIZATIONLIST

Medication-Related Problem Details Priority (Low, Medium, High)


MYMEDICATIONRELATEDACTIONPLAN

Patient: Doctor(Phone): Pharmacy/Pharmacist(Phone): DatePrepared:

ThelistbelowhasimportantActionStepstohelpyougetthemostfromyourmedications.FollowthechecklisttohelpyouworkwithyourpharmacistanddoctortomanageyourmedicationsAND

makenotesofyouractionsnexttoeachitemonyourlist.

ActionstepsWhatIneedtodo NotesWhatIdidandwhenIdidit.

MyNextAppointmentwithMyPharmacistison:______________(date)at_________AMPMThissampleMedicationRelatedActionPlan(MAP)isprovidedonlyforgeneralinformationalpurposesanddoesnotconstituteprofessionalhealthcareadviceortreatment.Thepatient(orotheruser)shouldnot,underanycircumstances,solelyrelyon,oractonthebasisof,theMAPortheinformationtherein.Ifheorshedoesso,thenheorshedoessoathisorherownrisk.Whileintendedtoserveasacommunicationaidbetweenpatient(orotheruser)andhealthcareprovider,theMAPisnotasubstituteforobtainingprofessionalhealthcareadviceortreatment.ThisMAPmaynotbeappropriateforallpatients(orotherusers).TheNationalAssociationofChainDrugStoresFoundationandtheAmericanPharmacistsAssociationassumenoresponsibilityfortheaccuracy,currentness,orcompletenessofanyinformationprovidedorrecordedherein.

ThisformisbasedonformsdevelopedbytheAmericanPharmacistsAssociationandtheNationalAssociation

ofChainDrugStoresFoundation.ReproducedwithpermissionfromAPhAandNACDSFoundation.




MedicationTherapyReviewSOAPNotesForm

Patient Name:

Patient ID: Insurance Company:

Date of Birth: Age:

Sex: Evaluation Date: Subjective (what the patient tells you):

Objective (information you gather from physical exam, labs): Assessment (problems you found, from most important to least important): Plan (what interventions will be initiated for each problem):




EnochTypewritten TextAvelina Espinas

EnochTypewritten Text83


EnochTypewritten TextF


EnochTypewritten Textcan't swollow food; need to suck on foodfeels she's gained weightfeels "shakey" when blood pressure high

EnochTypewritten Textbp: 136/85

2012_Preseminar Exercise Instructions.pdf2012_Preseminar Exercise_Toni2012_individual case part 1_Authorization for medication review2012_Individual case part 2_Patient history form2012_individual case part 3_MTM documentation

MTM Pre-Seminar Exercise Materials_2

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