Medication Review Guide

Manitoba Comprehensive
Medication Review Toolkit
Manitoba Comprehensive Medication Review Toolkit
TABLE OF CONTENTS
INTRODUCTION
SECTION ONE: WHAT IS A COMPREHENSIVE MEDICATION REVIEW?
What is a Comprehensive Medication Review?

Why Perform a Comprehensive Medication Review?
SECTION TWO: PREPARING FOR THE COMPREHENSIVE MEDICATION REVIEW
Staff Involvement
Scheduling Appointments
Tasks for the Patient
Getting Consent
SECTION THREE: CONDUCTING A COMPREHENSIVE MEDICATION REVIEW
12
Medical Information Gathering

A Systematic Medication Review Process
Identification of a Drug Therapy Problem
What if there are no Drug Therapy Problems?
Care Plan Development
Intervention Guideline
SECTION FOUR: FOLLOWING THE COMPREHENSIVE MEDICATION REVIEW
20
Communication with Health Care Practitioner(s)

Follow-up with the Patient
SECTION FIVE: COMPREHENSIVE MEDICATION REVIEW SUMMARY
23
Systematic Patient Review Process: An Overview

Comprehensive Medication Review Summary Checklist
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.
How to use this guide

The Manitoba Comprehensive Medication Review Toolkit takes you through the medication
review process from initial patient contact through follow-up. We would recommend you read
through the guide to familiarize yourself with the basic process and take advantage of the tools
provided. See Appendices for forms, response guides, helpful links and resources to build a
medication review program that works best in your practice. The program has been designed to
allow you to select the tools that help you to best serve the needs of your unique patient
population.
While this guide does cover the medication review process in some degree of detail, it is
important to remember that it is only a guide. The pharmacist must internalize a process to
ensure accurate and comprehensive collection of relevant patient information and thorough
analysis of drug therapy problems. Build your process to fit your practice setting and provide
the best possible care for your patients. Please note that certain forms may be necessary to use
in order to uphold standards of practice with regard to documentation.
Thank you for participating!

The Manitoba Society of Pharmacists (MSP) would like to thank you for making this effort to
expand the patient care services at your pharmacy. We hope you will find this guide helpful in
preparation for both the opportunities and challenges associated with comprehensive
medication reviews. Feedback is always appreciated as we endeavour to provide our
membership with the most relevant and up-to-date program possible.
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.
What is a comprehensive medication review?

During a comprehensive medication review, pharmacists perform a medication reconciliation
including prescription, non-prescription drugs, over the counter, and natural health products to
verify what medications a patient is taking and how they are taking them. It is also the
opportunity to reassess the appropriateness of the product (valid indication, appropriate
dosing) and screen for potential problems the medication may present to the patient (side
effects, drug interactions, etc).
Through this process, pharmacists may also discover medical issues that are not currently being
adequately treated, barriers to patient adherence and opportunities for further health
promotion, such as smoking cessation. If drug therapy problems (DTPs) are identified, some
may be addressed and corrected immediately or more time may be needed to develop a care
plan. This guide will assist you by helping you develop a process to resolve DTPs regardless of
the degree of complication.
In the event that no DTPs are identified, the review process is still a valid and important one as
patients better understand how to take their medications safely and appropriately. A
comprehensive medication review offers an opportunity to prevent future DTPs through
education and guidance.
Medication reviews are distinctly different from regular counseling sessions that occur day-today on newly prescribed and refilled prescriptions. A comprehensive medication review
requires a sit-down, face-to-face interview between the pharmacist and the patient (with or
without a caregiver, as appropriate) in a private patient counseling area. It is important to
differentiate these two patient care services as future compensation for a medication review
may only be provided if the program process is carried out and properly documented.
Why perform a comprehensive medication review?

As a highly trusted and readily accessible health care provider, pharmacists are well-positioned
to help their patients achieve optimal drug therapy outcomes.
The goals and objectives of a comprehensive medication review are as follows:
Assist patients in gaining a better understanding of their medications which in turn

promotes medication adherence
Maximize benefits associated with a patients medication regimen
Minimize risks associated with a patients medication regimen and uphold patient safety
Identify aspects of patient health where further attention is required
Identify and address areas of patient concern with regards to medication
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.
Who is a candidate for a comprehensive medication review?

There are many opportunities for medication reviews. These include, but are not limited to:
Patients diagnosed with or at risk of developing chronic conditions such as diabetes,

hypertension, heart failure, asthma, COPD, rheumatoid arthritis, chronic pain, etc
Patients taking more than one chronic medication or is currently prescribed medication
from more than one HCP
Patients taking high-risk medications such as warfarin, immunosuppressant drugs,

antiepileptics medication, opioids and benzodiazepines, etc
Elderly (65+) patients (especially those at risk for falls)
Patients presenting medication adherence challenges
Situations where there is drug abuse or misuse potential
Patient being discharged from hospital
Patient who receives a new diagnosis
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.
Tasks for the patient

Prior to the medication review, you may wish to have your patient fill out the Screening Tool
(See Appendix A) This questionnaire helps the patient self-identify issues with respect to
medication adherence, understanding of their medication regimen and personal feelings about
medication. This document can be sent home with the patient to fill out and bring to their
appointment or it can be completed in the 5-10 minutes before their review is scheduled. This
document assists the pharmacist in identifying what issues may need to be addressed during
the patient interview.
When the appointment is made, the patient should be asked to bring all their medications to
the appointment (prescription, over-the-counter, natural health products) as well as any
devices that they require (inhaler, aerochamber, blood glucose monitor, dosette, etc). A
reminder for this task can also be given during the reminder call.
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.
Medical Information Gathering

The information listed below follows the form Best Possible Medication History which can be
used to record all relevant patient background information. Keep in mind this is baseline
information only and referrals for further investigation to other professionals such as QUIT
trained pharmacists, Certified Diabetes Educators, and other areas of specialty may be
warranted.
1. Review completed Screening Tool to identify background problems and primary concerns of
the patient
2. Get consent from patient and caregiver, if present (see page 10 Getting Consent)
3. Collect other health information and lifestyle factors that may affect their medications and
overall health status
4. Document all patient disease states and medical conditions with relevant parameters
included
o E.g. Diabetes: include HgA1C, time of diagnosis, blood glucose readings, testing
frequency, history of hypoglycemia, etc.
Consider the following to assess renal function

o Are they likely to have decreased renal function? (E.g. Elderly, diabetic, known
renal disease, etc.)
o Calculate Creatinine Clearance (CrCl) using the most recent serum Creatinine
(sCr) level if available (see Appendix E)
5. Conduct a head-to-toe assessment of bothersome symptoms, complaints, and other health

related concerns (see Appendix D)
o Note: Further targeted line of questioning may be necessary when a patient
reports conditions/symptoms
6. Ask about Prescribed Medications, Non-prescribed Medications (OTCs), Natural Health

Products (Herbal products, Homeopathic Remedies, and Alternative Therapies) that are
taken on a regular and intermittent basis
Why are they taking this medication?
How do they take their medication?
How long have they been taking this medication?
Inquire about their experience with medication

o How has it been working for them?
o Have they been experiencing any unwanted side effects?
7. Have they recently stopped taking any of their medications?

This will conclude the medication reconciliation process. Ensure all other medications discussed
are included on the Best Possible Medication History for both patient and pharmacy records.
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.
A Systematic Medication Review Process

Once data has been collected and documented, it is essential that the pharmacist utilize a
comprehensive and systematic approach to identifying, preventing, and resolving potential and
actual drug therapy problems. This is an invaluable tool for pharmacists to develop as it
encompasses the core purpose of a comprehensive medication review, and is a skill set specific
to the pharmacist.
The document titled A Systematic Medication Review Process (see
Appendix C) should be used as an aid to develop this step-by-step approach.
1. Is there a documented indication for each drug?
Are all medications still necessary?
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?
3. For each medical condition or symptom:
Is the problem being caused by a drug?

o Consider: What drugs could cause similar signs/symptoms to this? What is the
time frame of the problem relative to current or recent drug use?
Have non-pharmacologic strategies been attempted?
Is the chosen therapy optimal for this patient?

o Consider: drug, dosing regimen, dosage form, safety, efficacy, drug interactions,
cost, convenience, adherence, time to onset, coverage by third party payers
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
6. Is the patient on any medications that require regular monitoring/adjustments?
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
Do any of their medications put them at risk of ototoxicity or oculotoxicity?

o See Appendix F
See Appendix G for link to normal lab values
7. How is the patients drug-taking behaviour?

o Consider: attitude, knowledge, physical/sensory/cognitive limitations, adherence
to therapy, daily routine, social situations
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
Identification of a Drug Therapy Problem

When a drug therapy problem is identified, it is important to recognize the urgency of the
situation and decide whether or not it can be dealt with in the pharmacy or if health care
practitioner referral is required. Some cases may require simple patient counseling and
clarification of current medications. Other issues may require further research by the
pharmacist and suggestions for interventions that will involve the physician and/or other health
care practitioners. Interventions and recommendations do not need to be complicated, but rely
heavily on communication.
Drug therapy problems that arise throughout the interview can be documented on the form
Drug Therapy Problems Identified (see Appendix A) and later prioritized in order of importance
and urgency. For those drug therapy problems which can be corrected with immediate action
and no further research or consultation, documentation can be completed at the bottom of this
form. Discussion with the patient and intention for follow-up should be indicated as well. For
those drug therapy problems requiring further research, contact with other health care
providers and care plan development, the form Pharmacy Care Plan (see Appendix A) can be
utilized and is discussed further below.
What if there are no Drug Therapy Problems?

Commend these patients on their effective management of their medications and conditions.
Remember that the review process is still a valid and important one as patients better
understand how to take their medications safely and appropriately. A comprehensive
medication review offers an opportunity to prevent future DTPs through education and
guidance.
Care Plan Development

A care plan is a tool to synthesize information collected, issues identified and prioritized,
planned interventions, desired outcomes, and strategies for monitoring and patient follow-up.
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
Objective measures such as blood pressure, lab results, etc.
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
See that the patient has necessary drugs and supplies

o Consider financial and insurance status
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.
Communication with Health Care Practitioner(s)

After the medication review and care plan(s) are complete, the pharmacist should complete
and send the Health Care Practitioner Communication Form (see Appendix A) for prescriber
input and authorization along with relevant sections of the Best Possible Medication History
(Section 4 Medical Conditions, Section 5 Medication List, etc) and the Pharmacy Care
Plan(s). The Health Care Practitioner Communication Form allows the pharmacist to
summarize the top priority drug therapy problems along with their recommendation, which
should be explicit in communicating the discontinuation of a drug (i.e. STOP drug A) or if
beginning a new medication where a prescription is required. This form can then be filled out
and signed by the physician and/or other health care practitioner on the right hand side and
sent back to the pharmacy for prescription communication purposes.
When using the Health Care Practitioner Communication Form, any therapies that the
pharmacist is recommending must include the drug name, strength, instructions (including
treatment goal depending on the HCP) and quantity to be dispensed including refills (and
interval information, when applicable) according to the College of Pharmacists of Manitobas
Joint Statement on Facsimile Transmission of Prescriptions. If the pharmacist includes all of this
information, this form can serve as a legal prescription.
Follow-up with Patient

Follow-up appointments, either by phone or in person, should be made with patients following
the comprehensive medication review. All follow-up appointments can be documented on the
Patient Follow-up Record (see Appendix A) and used for multiple follow-up arrangements if
necessary. Ensure the patient is given an up to date Best Possible Medication List (Part 5, page
4 of Best Possible Medication History Form) if changes are made after contact with the
physician and/or other health care practitioners.
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.

As you progress through your medication review, utilize this checklist as a guide to ensure all
components of the review are addressed.
Prior to the Review*:
Initials
Provide patient with Screening Tool to complete at home before appointment

Request patient bring all medications to the appointment including OTCs & NHPs
Print a list of patients active medications from your pharmacy software and/or DPIN
Assemble basic patient demographic information, acquire copies of health and
insurance cards
* The above tasks may be completed by any pharmacy team member
During the Review:

Explain nature of review process, discuss confidentiality and obtain patient consent
Review patients completed Screening Tool, take note of issues raised
Complete Best Possible Medication History form
o Add medications not on pharmacy file to medication history as they are
reviewed
Review each medication fully (including OTCs and NHPs) with the patient
Identify drug therapy problems (DTPs) based on preceding information and list on the
Drug Therapy Problems Identified form
Consult list of DTPs identified
o If no other input necessary, discuss the care plan with the patient and
implement immediately
o If more time is required, work up DTPs on Pharmacy Care Plan form
o Contact health care practitioner and/or other health care providers as
appropriate using the Health Care Practitioner Communication Form
Following the Review:
Schedule follow-up with the patient utilize Patient Follow-up Worksheet
Provide patient with a comprehensive, accurate, up-to-date medication list (signed by
the pharmacist retain a copy for your pharmacy records)
If warranted, provide patient with a Patient Action Plan
Initials
Initials
Appendices
Appendices Table of Contents

Appendix A Medication Review Forms
Screening Tool
Best Possible Medication History
Drug Therapy Problems Identified
Pharmacy Care Plan
Patient Action Plan
Patient Follow-up Record
Health Care Practitioner Communication Form
Appendix B Program Implementation Support
Medication Review Reminder
Sample Medication Review Schedule
Appendix C A Systematic Medication Review Process
Process flow chart and checklist
Appendix D Head to Toe Patient Assessment Guide
Appendix E Considering Kidney Function
Calculating creatinine clearance, eGFR
Manitoba Renal Program Resources
Appendix F Medication Reference Lists
High alert medications
List of ototoxic and oculotoxic medications
Appendix G Clinical Resources
Selected Clinical Practice Guidelines, Link to Clinical Practice Guidelines Database
Beers Criteria, STOPP tool
Link to Normal Lab Values
Appendix H Public Health Resources
Manitoba Vaccination Schedule
CCMB Cancer Screening Schedule
Lung Association
Smokers Help Line
Manitoba Society of Pharmacists
What is a Medication Review?

A Medication Review is a service
that involves your pharmacist
performing a complete assessment
of your medications
What benefits are there from having a
Medication Review?
Address any questions or concerns
that you have about your medicine
Ensure that you are receiving the
best medicine therapy possible
Increase your knowledge about
your medicine
Increase your confidence in using
your medicine
Reduce your risk of problems from
your medicine
Are You Getting the Most

from Your Medications?
Manitoba Society of Pharmacists
Are you taking several medications
Do you ever have trouble using your
(including natural products and non-
medicines (swallowing, puffers, eye
prescription products)
drops, patches)
Do you have more than one doctor or

other health care provider
Do any of your medications make you
feel unwell
Does the cost of your medicine make it
hard for you to take it as prescribed
Do you have trouble understanding or
remembering how to take your
Do you feel that you are taking too

many medicines
Do you worry that your medicines are
working against each other
Have you recently been discharged
from the hospital
Do you wish you knew more about your
medicine
medicine
* If any oIf any of these apply to you, talk to your pharmacist about whether a Medication Review is right for you.
Pharmacy Contact Information Here

Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________

1. Patient Information
Name
Gender
Male
Age
Third Party Coverage
Family Physician
Female
Address
Postal Code
Reason for Med Review
Undifferentiated
City/Province
Phone #
Other Physician/Specialist
Caregiver (if applicable)
Pharmacist Completing Review
Phone #
License No.
What is your primary concern about your medications today?
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:_______________________________________________

Patient Name:
PHIN:
DOB:
Phone:
3. Health Information and Lifestyle Factors
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:
Grapefruit (Juice) Consumption
Y N
Nutritious Diet
Y N
Restricted Diet
Y N
Physically Active
Type of activity:
Minutes/week:
Recreational/Other Drug Use
Y N
Yearly Influenza Immunization
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
Regular or recent lab tests
Y N
Date/Result:
Height:
Weight:
Do you live alone?
Normal Overweight
Underweight
Y N
Aids, Alerts, Devices, etc.
Other
Y N
Please list:
Y N
What/When:
Y N
(copy & attach results if possible)
Body Mass Index (BMI)
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.
Head to toe Assessment regarding other complaints/concerns/bothersome symptoms:

Do any ever require self treatment?
Family History
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
5. Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)

Issues Identified
Medication
How Taken
Name, Strength
Dose, Route, Frequency, Time

of Day, Special Instructions
Purpose for Use
How long taken
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Additional
Comments
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
6. Recently Discontinued Medications

Medication
How Taken
Name, Strength
Dose, Frequency, Time of Day,

Special Instructions
Purpose for Use
How long taken?

When was stopped?
Who stopped it?

Reason for Stopping?
Require Further
Action?
Yes:
No:
Proceed
to DTPs
Identified
Verify to
continue
as per
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
No drug therapy problems were identified
Priority Number
Drug Therapy Problem (DTP)
_____
_________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
_____
__________________________________________________________________
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: _____________________
Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have
collected.
Assessment: State the drug therapy problem.
Plan: For each alternative, consider treatment efficacy, safety, drug interactions, adherence,
cost, drug coverage and non-pharmacological interventions.
Alternative #1:
Alternative #2:
Monitoring:
Planned date of follow-up: ____________________________

____________________________________
__________________________
Date of Review
Patient Name:
PHIN:
DOB:
Phone:
Pharmacist: _____________________
Patient Action Plan

Date of Comprehensive Medication Review: _________________________
As a result of my comprehensive medication review, I will do the following:
1.
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: _____________________

Date of Follow-Up
Reason for Follow-up
Results
Pharmacist Comments & Plan

Intervention complete? Yes No
Any new concerns?

Pharmacist signature: _______________
Any new concerns?

Any new concerns?


Date:_______________________
Health Care Practitioner
Re: (Patients Name)
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.
We have scheduled a medication review for _________________

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.)
Pharmacy Business Card Here
MED REVIEW REMINDER
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.
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.
Pharmacy Business Card Here
MED REVIEW REMINDER

We have scheduled a medication review for _________________
SAMPLE MEDICATION REVIEW SCHEDULE

Monday
NAME
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
1. Is there a documented indication for each drug?
Are all medications still necessary?
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?
3. For each medical condition or symptom:
Is the problem being caused by a drug?

o Consider: What drugs could cause similar signs/symptoms to this? What is the time
frame of the problem relative to current or recent drug use?
Have non-pharmacologic strategies been attempted?
Is the chosen therapy optimal for this patient?

o Consider: drug, dosing regimen, dosage form, safety, efficacy, drug interactions, cost,
convenience, adherence, time to onset, coverage by third party payers
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
6. Is the patient on any medications that require regular monitoring/adjustments?
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
Do any of their medications put them at risk of ototoxicity or oculotoxicity?

o See Appendix G
See Appendix H for normal lab values
7. How is the patients drug-taking behaviour?
Consider: attitude, knowledge, physical/sensory/cognitive limitations, adherence to therapy,

daily routine, social situations
8. Are there any other issues that affect medication use in this client?
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
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
Check for drug duplication

Check for drug interactions (drug-drug, drug-food, drug-disease, drug-lab,
etc.)
Check that medications and diseases correspond
Check that patient has been renewing prescriptions and that they have been
taking their medications according to prescription
The patient is taking/receiving a drug for which there is no valid indication

The patient requires therapy for an indication and is not receiving therapy
The patient is taking/receiving the wrong drug or drug product
The patient is taking/receiving an inappropriate dose of a drug
The patient is not taking/receiving the prescribed drug appropriately
The patient is experiencing an adverse drug reaction
The patient is experiencing a drug interaction
The patient requires certain lab tests and monitoring
The patient is currently taking a medication that is ineffective for the
condition being treated (treatment failure)
If interaction with other health care practitioner(s) is required, report DTP to

patients physician and/or health care practitioner using the Health Care
Practitioner Communication form for collaborative resolution. Inform
patient of care plan and of outcome when response received, ensuring the
patient is given a comprehensive, accurate and up- to-date medication list
from the Best Possible Medication History form along with the Patient
Action Form.
Source: The NB Department of Health, the New Brunswick Pharmacists Association, and the Canadian Pharmacists Association. (2010).
Program Guidance Document, NB Pharmacheck.

As you progress through your medication review, utilize this checklist as a guide to ensure all
components of the review are addressed.
Prior to the Review*:
Initials
Provide patient with Screening Tool to complete at home before appointment

Request patient bring all medications to the appointment including OTCs & NHPs
Print a list of patients active medications from your pharmacy software and/or DPIN
Assemble basic patient demographic information, acquire copies of health and
insurance cards
* The above tasks may be completed by any pharmacy team member
During the Review:

Explain nature of review process, discuss confidentiality and obtain patient consent
Review patients completed Screening Tool, take note of issues raised
Complete Best Possible Medication History form
o Add medications not on pharmacy file to medication history as they are
reviewed
Review each medication fully (including OTCs and NHPs) with the patient
Identify drug therapy problems (DTPs) based on preceding information and list on
the Drug Therapy Problems Identified form
Consult list of DTPs identified
o If no other input necessary, discuss the care plan with the patient and
implement immediately
o If more time is required, work up DTPs on Pharmacy Care Plan form
o Contact health care practitioner and/or other health care providers as
appropriate using the Health Care Practitioner Communication Form
Following the Review:
Schedule follow-up with the patient utilize Patient Follow-up Worksheet
Provide patient with a comprehensive, accurate, up-to-date medication list (signed
by the pharmacist retain a copy for your pharmacy records)
If warranted, provide patient with a Patient Action Plan
Initials
Initials
Head to Toe Assessment Guide

Source: Regional Pharmacy Services, Alberta Health Services, (2011). Patient Care Process. Faculty of Pharmacy and Pharmaceutical Sciences.
University of Alberta, Edmonton Alberta.p.3,5.
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
energy levels, weight changes, ailments, pain

rashes, dryness, pruritus, hair loss, nails
mental status, headache, syncope, seizures, tremor, weakness,
vertigo, sleep changes, anxiety, depression
redness, discharge, blurring, vision, pain, glaucoma, cataracts
hearing loss, tinnitus, earache, discharge
rhinitis, sinus congestion, discharge
dentition, hoarseness, pharyngitis, ulcerations
swollen lymph nodes/glands, goiter, pain
cough, dyspnea, wheezing, sputum, asthma, bronchitis, pneumonia
chest pain, murmurs, palpitations, hypertension, myocardial
infarction
dysphagia, odynophagia, reflux, nausea, vomiting, bowel movements,
stool
pain, frequency, urgency, incontinence, retention, bleeding
organ function, infection (hepatitis, pyelonephritis)
libido, discharge, infection, menstrual, menopause
stiffness, pain, motion, swelling, redness, deformities
thyroid, diabetes, adrenals, estrogen, testosterone
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
lifestyle? What is the severity of the symptom? (mild, moderate,

severe)
What is the frequency of the symptom?
What is the duration of the symptom? When did it first present?
What was the patient doing when the symptom first presented?
Are there any relieving or aggravating factors? What makes it better
or worse?
Are there any associated symptoms? (Include absence of symptoms if
relevant- i.e. no fever, no cough, no dyspnea, etc.)
Source: Giberson S, Stein E. Performing patient assessment: a pharmacy perspective. Pharmacy Times 2002;68(12):44-48..
Estimating Renal Clearance: Practical Tips for the Pharmacist

Estimating Creatinine Clearance for Drug Dosing Adjustments
Cockcroft and Gault1:
Normalized for weight:
(140) 88.4
(
)
x 0.85 if female
Patient weight included:

(140) () 1.23
(
)
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
Children (<18 years old)
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
Estimation of Glomerular Filtration Rate (eGFR)

Note: eGFR is used to classify Stages of Renal Disease and SHOULD NOT be used to adjust drug dosages or dosing intervals. Drug companies list
dose adjustments in the drug monographs based on the Cockcroft and Gault equation.2 Please see the Manitoba Renal Program Resources
(below) on how to use eGFR in clinical practice.
Modification of Diet in Renal Disease (MDRD) 4-Variable Equation11
Link to Calculator: http://www.globalrph.com/crcl_idms.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.
Chronic Kidney Disease in Epidemiology (CKD-EPI) Equation12

Link to Calculator: http://www.globalrph.com/gfr-epi.htm
Was developed to improve some of the limitations of the MDRD equation

Can be used to predict eGFR in patients with renal function above 60mL/min/1.73m2
Manitoba Renal Program Resources

How to Use eGFR
http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/how-to-use-egfr/
Stages of Chronic Kidney Disease Definitions (Stages 1-5)
http://www.kidneyhealth.ca/wp/healthcare-professionals/egfr-referral-pathways/mrp-chronic-kidney-disease-stages/
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.
Common High-Alert Medications

These medications often require close monitoring and special attention with respect to drug
interactions, side effects/toxicity and in some cases misuse potential. It may also be necessary to
order drug levels or other lab indices to assess therapy with these medications. Please note this is not
an exhaustive list.
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
Drugs causing QT prolongation

An up to date list of drugs that cause QT prolongation can be found at www.qtdrugs.org
Common Ototoxic Medications:

Medication
Furosemide
Salicylates
Erythromycin
Quinine
Aminoglycosides
Cisplatinum
Effect
Reversible hearing loss
Reversible hearing loss (bilateral)
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.
Common Oculotoxic Medications:

Medication
Chlorpromazine
High-dose Corticosteroids
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
Selected Clinical Practice Guidelines:

2013 CHEP Recommendations for the Treatment of Hypertension:
http://hypertension.ca/images/CHEP_2013/2013_CompleteCHEPRecommendations_EN_HCP1009.p
df
Canadian Cardiovascular Society Guidelines for Diagnosis and Treatment of Dyslipidemia for
Prevention of Cardiovascular Disease (2012 update):
http://download.journals.elsevierhealth.com/pdfs/journals/0828-282X/PIIS0828282X12015103.pdf
Canadian Diabetes Association 2013 Clinical Practice Guidelines:
http://guidelines.diabetes.ca/
Canadian Thoracic Society Asthma Treatment Guidelines and Updates:
http://www.respiratoryguidelines.ca/guideline/asthma
Canadian Thoracic Society COPD Treatment Guidelines and Updates:
http://www.respiratoryguidelines.ca/guideline/chronic-obstructive-pulmonary-disease
CAN-ADAPTT Canadian Smoking Cessation Clinical Practice Guideline:
https://www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CANADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf
SOGC Clinical Practice Guideline Menopause and Osteoporosis Update 2009:
http://www.sogc.org/guidelines/documents/Menopause_JOGC-Jan_09.pdf
Canadian Neurological Sciences Federation Canadian Guidelines on Parkinsons Disease:
http://www.parkinsonclinicalguidelines.ca/sites/default/files/PD_Guidelines_2012.pdf
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
Resources to Assess Medications for the Elderly:

American Geriatric Society Beers Criteria 2012 for Potentially Inappropriate Medication Use in
Older Adults:
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_r
ecommendations/2012
Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP):
http://ageing.oxfordjournals.org/content/37/6/673.full.pdf+html
Evidence-Based Medicine Research Resources:

Trip Database: http://www.tripdatabase.com/
Essential Evidence Plus: http://www.essentialevidenceplus.com/
Laboratory Monitoring Resources:

Diagnostic Services of Manitoba - Normal Laboratory Values Database:
https://apps.sbgh.mb.ca/labmanualviewer/index.do
Government of Manitoba Communicable Disease Control:

Immunizations and Vaccinations Homepage:
http://www.gov.mb.ca/health/publichealth/cdc/div/index.html
Manitoba Routine Immunization Schedules:
http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html
Cancer Care Manitobas Cancer Screening Programs:

BreastCheck:
http://www.cancercare.mb.ca/home/prevention_and_screening/general_public_screening_program
s/manitoba_breast_screening_program/
CervixCheck:
s/manitoba_cervical_cancer_screening_program/
ColonCheck:
s/manitoba_colorectal_screening_program/
Lung Association Find a lung function testing lab or spirometry clinic in your area:
http://www.lung.ca/respDB/search-testing_e.php
Smokers Help Line:

http://www.smokershelpline.ca/
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:
Name
Age
Elizabeth Martin
Gender
Male
Female
23
Pharmacare
Family Physician
Dr. Cares Mountain Medical
Undifferentiated
Address
City/Province
423 Anywhere St
Postal Code
X0X 0X0
Winnipeg, MB
Phone #
Dr. Woods Respirologist, HSC

Phone #
(204) 555-2053
Recently hospitalized for asthma
Pharmacist Completing Review
License No.
S. Robinson
123456
exacerbation
Patient is concerned about recent hospitalization and would like her breathing to
improve.
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.
You also have a print out of Elizabeths pharmacy medication profile:

Medication
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
1-2 puffs prn

1-2 puffs prn
1-2 puffs prn
1-2 puffs prn
1-2 puffs prn
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:__
Elizabeth Martin ___________________________________
Patient has agreed that information may be shared with their physician and other healthcare
providers
Elizabeth Martin____________________________________
Patient consents to having patient representative/caregiver present to receive service

(if applicable)
Name of Representative(s):_______________________________________
Patient Signature:_______________________________________________
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
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
Tries to eat healthy, feels she
Y N
Type of activity: Gym 2-3x/week
Physically Active
Worst in spring, worsens asthma
Worsens her asthma
Cigarettes/day: 10/day
could do more
Minutes/week: 90 mins/week
Y N
Y N
(if over 65)
Other Vaccinations (travel,
routine, etc.)
Y N
Screening Completed (breast,

colon, cervical, etc.)
Y N
Eye Exam, Hearing test within

last year
Y N
Y N
Date/Result:
Height:
Weight:
Do you live alone?
Normal Overweight
Underweight
Y N
Other
No aerochamber for MDI
Y N
Please list: Routine vaccinations up

to date
When:
Has never had pap test
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.
Kidney Disease? Liver Disease? BP = HR = RR =
CrCl =
1.
Asthma x 15 years
2.
Seasonal allergies x 5 years
Used salbutamol at least BID for last 2
Worst in spring, beginning just as snow begins
weeks, feels symptoms with exercise, has
to melt; utilizes antihistamine prn for
missed work due to recent hospitalization
symptoms
for exacerbation
Occasional headaches from working too long on the computer

Family History
Heart disease, Father had MI (age 49)
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.
Medication
How Taken
Name, Strength
Dose, Route,
Frequency, Time
of Day, Special
Instructions
Purpose for Use
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
Has used BID x
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
Takes with food,
menstrual cramps
years
no stomach pain
For cold/flu
Not
Last use 3
symptoms
known
months ago
For seasonal allergies
4 years
Only uses prn,
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.
Medication
How Taken
Name, Strength
Dose, Frequency,
Time of Day,
Purpose for
Use
How long taken?

When was
stopped?
Require
Further
Action?
Who stopped it?

Budesonide 200 mcg
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:
Medication
Name, Strength
How Taken
Dose, Route,
Frequency, Time
of Day, Special
Instructions
Purpose for Use
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
Has used BID x
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
Takes with food,
menstrual cramps
years
No
For cold/flu symptoms
Not
No
Last use 3
Yes
Only uses prn,
400 mg tablets
Buckleys All-in-
Prn (OTC)
One
Cetirizine 10 mg
known
1 tab daily
Prn (OTC)
For seasonal allergies
4 years
no stomach pain
months ago
not regularly

Medication
Name, Strength
How Taken
Dose, Frequency,
Time of Day,
Purpose for
Use
How long taken?

When was
stopped?
Who stopped it?

Budesonide 200 mcg
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.

Priority Number
1

Elizabeth is experiencing poorly controlled asthma due to non-use of
fluticasone (controller medication).
Elizabeth smokes cigarettes, despite having asthma, and thus risks

worsening her asthma symptoms.
Elizabeth has not received her annual flu shot.
Elizabeth experiences uncontrolled seasonal allergies due to irregular

use of an antihistamine.
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
Assess patient readiness to quit

Refer to QUIT trained pharmacist on staff
Suggest patient utilize daily antihistamine
during allergy season as opposed to prn
Utilize non-pharm approaches
(doors/windows closed, regular laundering of
outdoor clothes, etc)
Educate patient about the importance of flu

shot; direct to local flu shot clinics
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.
Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have collected.
Elizabeth has been using her salbutamol rescue medication at least BID for the last 2 weeks, has
symptoms when she exercises and was recently hospitalized for an acute asthma exacerbation.
All of these facts indicate poor asthma control. Her respirologist switched her controller
medication from a budesonide turbuhaler to a fluticasone MDI in November 2012. Elizabeth
used fluticasone for 2 weeks and then stopped using it because she did not like the taste of the
spray. Since then, she has only been using salbutamol for relief of acute symptoms.

Elizabeth is experiencing poorly controlled asthma and requires a daily inhaled corticosteroid to
regain control and decrease the need for rescue doses of salbutamol.
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____________________
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
Assess patient readiness to quit
Yes, not
Ongoing at refills
Refer to QUIT trained pharmacist on staff
ready to
Provided pt with
quit
reading material
Yes,
Phone reminder
Suggest patient utilize daily antihistamine during

allergy season as opposed to prn
patient
mid-March when
Utilize non-pharm approaches (doors/windows
agrees
snow begins to melt
closed, regular laundering of outdoor clothes, etc)
Educate patient about the importance of flu shot;

direct to local flu shot clinics
Yes
Will direct to flu

shot clinic in fall
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.
Your pharmacy business card goes here
Date:_March 4, 2013__
Re: (Patients Name)
PHIN
Dr. Cares
Elizabeth Martin
123456789
Address
Address
Mountain Medical Clinic 42 White Blvd
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.
Patient wasnt using fluticasone
inhaler due to unpleasant taste.
Information Only
Pharmacist Signature: S. Robinson
Prescriber Comments/Revisions
Action Required
Plan to restart fluticasone with
Yes
No
Yes
No
aerochamber, follow-up in 1 week

Information Only
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:

Date of
Follow-up
11/03/2013 Medication review 1 week
Results
Aerochamber working well, 0
ago, follow-up re: use of
bad taste; only using rescue
fluticasone inhaler,
medication once/day still
aerochamber use, control
needs improvement
of asthma symptoms
Improved exercise, generally
25/03/2013 Second follow-up to assess
Should be using salbutamol <4x

per week, will contact in 2
weeks
feeling better
Any new concerns?
Pharmacist signature: S. Robinson
Now only needing salbutamol
asthma control, hope to
inhaler approx once/week
have decreased use of
No issues with exercise,
salbutamol
asthma symptoms <4x/week

Any new concerns?
04/04/2013 Reminder call to start daily Patient planning to use

antihistamine to control
cetirizine 10 mg daily,
seasonal allergies
starting tomorrow
Any new concerns?
Plan to refer to CRE for further

asthma monitoring

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.
Name
Age
Steve Wilkinson
Gender
Male
Female
72
Pharmacare, Blue Cross

Family Physician
Undifferentiated
Address
City/Province
Dr. Johnson Lakeside Clinic

123 Somewhere Ave

Postal Code
Winnipeg, MB
Phone #
Dr. Howard Cardiologist

X0X 0X0
(204) 555-5555
Lila Smith (daughter) (204)123-4567

Pharmacist Completing Review License No.
Vacationing in Arizona for 3 months

M. Anderson
Phone #
999000
Steve is concerned about having all medications and vaccinations up to date before
leaving for Arizona.
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.
Steves medication profile printout:

Medication
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
Steve Wilkinson ___________________________________
Patient has agreed that information may be shared with their physician and other healthcare
providers
Steve Wilkinson____________________________________
Patient consents to having patient representative/caregiver present to receive service

(if applicable)
Name of Representative(s):___Lila Smith (daughter)___________________
Patient Signature:____
Steve Wilkinson _________________________
3. Health Information and Lifestyle factors

Inquiry
Allergies
Yes/No
Y N
Details/Comments
Reaction:
Penicillin
Hives
Codeine
Stomach Pain
Smoker
Y N
Former Smoker
Cigarettes/day: 1 pack (25)
Alcohol Consumption
Y N
Drinks/week:
Caffeine Intake
Y N
Drinks/day: 3
Grapefruit (Juice)
Consumption
Y N
Drinks GF Juice occasionally
Nutritious Diet
Y N
Restricted Diet
Tries to follow DASH diet, wife
Y N
Type of activity: walks dog, curls
Physically Active
x_10_years
makes sure he eats healthy

Minutes/week: 20 mins/night
(walk), 2-3 hours/week (curling)
Y N
Y N
(if over 65)
Other Vaccinations (travel,
Y N
Y N
Please list:
Screening Completed (breast,

colon, cervical, etc.)
Y N
When:
Eye Exam, Hearing test within

last year
Y N
Y N
Date/Result:
Height:
Weight:
Do you live alone?
Normal Overweight
Underweight
Y N
Other
Penicillin Allergy Bracelet
routine, etc.) Doesnt know

Colon check - April 2012
Kidney Disease? Liver Disease? BP = 137/84
CrCl =
1.
Hypertension
2.
HR =
RR =
High cholesterol
-checks own BP regularly with
-unknown recent LDL/HDL
at home monitor
levels
5.
Hx of MI
3.
BPH
- Dr has ruled out cancer
4.
Glaucoma
-five year history

-unsure which type
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

Issues Identified
Medication
How Taken
Name, Strength

Ramipril 5 mg
Metoprolol 25mg
Purpose for Use
1 cap daily with
blood pressure, protect
breakfast
heart
1 tab twice daily with
How long taken
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
breakfast and supper

Atorvastatin 20mg
1 tab daily with supper
lower cholesterol
3 years
yes
Drinks GF juice
Clopidogrel 75mg
1 tab daily with
thin blood
2 years
yes
Post-MI
1 tablet daily with
thin blood, protect
3 years
no
Buys OTC
breakfast
heart
1 drop each eye at
Glaucoma
5 years
no
breakfast
ASA 81mg
Latanoprost 0.005%
bedtime
Tamsulosin 0.4mg
1 cap daily at supper
BPH
4 years
no
Diphenhydramine 50mg
1 cap at bedtime
Sleep disorder
1-2 months
yes
Started taking because it

makes him drowsy
Vitamin E 800IU
Mens Multivitamin
1 cap daily with
Supplement, keep
1 year
yes
Buys OTC, heard it was
breakfast
heart healthy
1 tab daily with
Supplement
5 years
no
Buys OTC
Headaches, pain, etc.
PRN
no
Buys OTC
good for his heart
breakfast
Acetaminophen 325mg
PRN
6. Recently Discontinued Medications - None
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.

Priority Number
4

Steve is at risk of receiving inadequate therapy in the future due to
misidentification of codeine allergy.
Steve is a candidate for the pneumococcal vaccination.
Steve is at risk of experiencing a drug-food interaction with statin therapy

use and grapefruit juice consumption.
Steve is experiencing urinary symptoms and bladder infections due to

anticholinergic effects of diphenhydramine use.
Steve is at risk of an adverse event secondary to Vitamin E use
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
Educate Steve on interaction and advise him to
yes
avoid drinking GF juice while on atorvastatin.
None- patient
agrees to avoid GF
consumption
Inform Steve on current evidence for vitamin E
yes
None- patient
and advise he discontinue use. Ensure him that
agrees to stop
cardiac medications he is currently prescribed are
taking vitamin E
ideal for his conditions.
Explain difference between allergy and

intolerance regarding codeine to clarify possibly of
benefit if needed for future treatment.
yes
Update pharmacy
profile
Educate Steve about the importance of the

pneumococcal vaccination and how he is a
yes
Direct to local
vaccination clinics
candidate for getting this shot
Pharmacy Care Plan

Data: Subjective information provided by the patient and/or objective data that you have collected.
Steve has been experiencing urinary symptoms over the past month including burning while he
pees and increasing difficulty going the washroom. Steve was recently treated on December 22,
2012 for a UTI with SMX/TMP 2 tabs twice daily for 3 days. Steve has recently started using
diphenhydramine to help him sleep over the past 1-2 months, and has not spoken to the
doctor about his difficulty with sleeping. Steve has had trouble sleeping for the past few years,
and it is becoming increasingly worse. It takes him 1-2 hours to fall asleep and he wakes up
several times during the night. Steve also has a history of MI (2010), hypertension,
hypercholesterolemia, glaucoma, and BPH.

Steve is experiencing a drug-disease interaction between diphenhydramine and BPH that may
be causing urinary problems due to inappropriate therapy for sleep difficulty and requires a
change in treatment.
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
December 28, 2012___

Date of Review
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.
Your pharmacy business card goes here
Date:_January 3, 2012__
Re: (Patients Name)
Dr. AlexJohnson
Steve Wilkinson
Address
Address
PHIN
123456789
Lakeside Clinic 497 Crescent Ave
123 Somewhere Ave
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.
Steve is experiencing urinary
problems due to diphenhydramine
use and a history of BPH, and
requires appropriate therapy for
sleep difficulty.
Information Only
Pharmacist Signature: MAnderson
Prescriber Comments/Revisions
Action Required
Initiate therapy with Zopiclone 3.75 mg
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
Prescriber Signature: AJohnson

License #: 12345
Date: January 8, 2013
Patient Action Plan

Date of Comprehensive Medication Review: December 28/2012, January 9/2013
As a result of my comprehensive medication review, I will do the following:
1. Stop using diphenhydramine to help me sleep and start using zopiclone instead
-take it just before bedtime if I need to
-watch for side effects and improvements talked about with pharmacist
2. I will work on my sleep hygiene
-dont drink afternoon coffee, try to avoid afternoon nap and nighttime snacking,
keep regular schedule of going to bed/waking up, keep going for after supper
walks, make sure room is dark, comfortable, and quiet for sleeping
3.
Dont drink grapefruit juice or eat grapefruit while Im on Lipitor
4.
I will get my pneumococcal vaccination
5.
I will stop taking vitamin E
6.
I will talk to the doctor about codeine allergy
Medications (Prescription, Non-Prescription, Natural Health Products, Homeopathic Remedies)

Updated: January 9, 2013
Issues Identified
Medication
How Taken
Name, Strength

Ramipril 5 mg
Metoprolol 25mg
Purpose for Use
1 cap daily with
blood pressure, protect
breakfast
heart
1 tab twice daily with
How long taken
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
breakfast and supper

Atorvastatin 20mg
1 tab daily with supper
lower cholesterol
3 years
no
Clopidogrel 75mg
1 tab daily with
thin blood
2 years
no
Post-MI
1 tablet daily with
thin blood, protect
3 years
no
Buys OTC
breakfast
heart
1 drop each eye at
Glaucoma
5 years
no
breakfast
ASA 81mg
Latanoprost 0.005%
bedtime
Tamsulosin 0.4mg
1 cap daily at supper
BPH
4 years
no
Mens Multivitamin
1 tab daily with
Supplement
5 years
no
Buys OTC
breakfast
Acetaminophen 325mg
PRN
Headaches, pain, etc.
PRN
no
Buys OTC
Zopiclone
1 tab at bedtime
Sleep disorder
new
no
Follow-up required

Date of
Follow-up
9/01/2013
Results
Medication review 2 weeks
Steve has been counseled and
ago, follow-up regarding
understands how to use
counseling on initiation of
zopiclone to manage his sleep
new treatment with
disorder, and has been given
zopiclone and changes to
information to improve his
sleep hygiene.
sleep hygiene.
Any new concerns?
Pharmacist signature: MAnderson
Steve has noticed it doesnt
23/03/2013 Follow-up call to assess

improvement in sleep
take him as long to fall asleep
pattern.
but still finds he is waking up

frequently throughout the
01/02/2013 Follow-up call to assess
Follow-up in two weeks to assess

effectiveness and side effects of
zopiclone.
Contact physician for increase in

dose to 5mg of zopiclone.
night.
Any new concerns?
Large improvement in Steves
improvement in sleep
sleep schedule, and he is no
pattern with increase in
longer having the same
dose.
urinary symptoms described

earlier in med review.
Any new concerns?
Update medication history

forms to reflect increased dose
of zopiclone.

Medication Review Guide

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Medication Review Guide

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Manitoba Comprehensive

Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

SECTION ONE: WHAT IS A COMPREHENSIVE MEDICATION REVIEW?

What is a Comprehensive Medication Review?

Medical Information Gathering

Communication with Health Care Practitioner(s)

Systematic Patient Review Process: An Overview

Manitoba Comprehensive Medication Review Toolkit

How to use this guide

Thank you for participating!

Manitoba Comprehensive Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

What is a comprehensive medication review?

Manitoba Comprehensive Medication Review Toolkit

Why perform a comprehensive medication review?

Assist patients in gaining a better understanding of their medications which in turn

Maximize benefits associated with a patients medication regimen

Identify aspects of patient health where further attention is required

Identify and address areas of patient concern with regards to medication

Manitoba Comprehensive Medication Review Toolkit

Who is a candidate for a comprehensive medication review?

Patients diagnosed with or at risk of developing chronic conditions such as diabetes,

Patients taking high-risk medications such as warfarin, immunosuppressant drugs,

Elderly (65+) patients (especially those at risk for falls)

Patients presenting medication adherence challenges

Situations where there is drug abuse or misuse potential

Patient being discharged from hospital

Patient who receives a new diagnosis

Manitoba Comprehensive Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

Tasks for the patient

Manitoba Comprehensive Medication Review Toolkit

Manitoba Comprehensive Medication Review Toolkit

Medical Information Gathering

Consider the following to assess renal function

5. Conduct a head-to-toe assessment of bothersome symptoms, complaints, and other health

Manitoba Comprehensive Medication Review Toolkit

6. Ask about Prescribed Medications, Non-prescribed Medications (OTCs), Natural Health

Why are they taking this medication?

How do they take their medication?

How long have they been taking this medication?

Inquire about their experience with medication

7. Have they recently stopped taking any of their medications?

Manitoba Comprehensive Medication Review Toolkit

A Systematic Medication Review Process

The document titled A Systematic Medication Review Process (see

Appendix C) should be used as an aid to develop this step-by-step approach.

1. Is there a documented indication for each drug?

Are all medications still necessary?

3. For each medical condition or symptom:

Is the problem being caused by a drug?

Have non-pharmacologic strategies been attempted?

Is the chosen therapy optimal for this patient?

Manitoba Comprehensive Medication Review Toolkit

6. Is the patient on any medications that require regular monitoring/adjustments?

Do any of their medications put them at risk of ototoxicity or oculotoxicity?

See Appendix G for link to normal lab values

7. How is the patients drug-taking behaviour?

Manitoba Comprehensive Medication Review Toolkit

Identification of a Drug Therapy Problem

What if there are no Drug Therapy Problems?