Pharmacy Record Abstraction Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Att 8_ Pharmacy Rec Abstract Form

Pharmacy Record Abstraction Form

OMB: 0920-1019

Document [docx]
Download: docx | pdf

Attachment 8 Patient Project ID: __________

Staff Project ID: __________

Pharmacy Project ID: __________



Form Approved

OMB No: 0920-XXXX

Exp. Date: XX/XX/XXXX







Pharmacy Record Abstraction Form







Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)





Pharmacy Record Abstraction Form

Was Medication Therapy Review conducted in the past 3 months? □ yes □ no

Was a Personal Medication Record completed? □ yes □ no date: _____/_____/____

Was a Medication-related action plan conducted? □ yes □ no date: _____/_____/____

Was individualized adherence support provided? □ yes □ no date: _____/_____/____

Pharmacist’s Recommendations (use additional pages for each additional recommendation)

What kind of Medication Therapy Review was conducted?

Targeted Medication Review

Comprehensive Medication Review

Medication reconciliation

Scheduled medication follow-up

date: _____/_____/____

Medication name/strength/dose:

Conflicting Drug or Disease State (if applicable):

General therapy issue (s) identified

HIV specific therapy issue(s) identified



Suggested Resolution



(see Appendices 1 and 2)

Pharmacist Recommendation

Clinic contacted?

Was an action plan developed with clinic?

Describe action plan

Non-HIV health conditions identified




discrepancies between medication lists

drug interaction

insufficient dose/duration

excessive dose/duration

unnecessary therapy

suboptimal drug therapy

adherence—over/underuse

administration technique

adverse drug reaction

complex drug therapy

cost efficacy

other




needs therapy

suboptimal drug therapy

complex drug therapy

over-the-counter therapy

not on 3 active HIV drugs

not on preferred regimen

on single tablet regimen and another ARV*

not on appropriate prophylaxis

HIV viral load levels are detectable

co-infected with HIV/HBV^ and not on a preferred regimen

CrCl† ≤60 min/mL or goes ≥25% from baseline

rise in LFTs‡

patient is on tenofovir but no serum Creatinine has been drawn

ARV therapy is not synchronized to be filled on the same date

patient has been without ARVs for 3 or more consecutive days OR 9 days total in the 90 day period.



yes □ no

How was clinic contacted?

phone

fax

email

in person

other:



Date clinic contacted:






__/__/___

yes □ no

How did clinician accept recommendation?

phone

fax

email

in person

other:



Date clinician accepted recommendation:





__/__/___


# of non-HIV conditions identified: ____



Non-HIV conditions identified:

(see Appendix 3)

* ARV = antiretroviral ^HBV = hepatitis B virus †CrCl= Creatinine clearance ‡LFTs= liver function tests




Is follow-up with patient required? □ yes □ no Follow-date(s): date: _____/_____/____

Was a pharmacist recommendation or pharmacist/clinic action plan implemented? □ yes □ no

For patients with adherence problems identified during the CMR/TMR(s), were barriers to adherence identified? □ yes □ no

If yes, please complete the following:

Identified Adherence to Therapy Barriers (use additional pages for each additional medication)

Medication name/strength/frequency:

Barrier(s) identified

Intervention or Recommendation

Clinic contacted?

Clinician accepts recommendation?


If no, was action plan developed with clinic?

Describe action plan

poor understanding of when and how often to take meds

patient education/monitoring


yes □ no

yes □ no □ N/A

yes □ no □ N/A




poor understanding of why they need to take meds

patient education/monitoring


yes □ no

yes □ no □ N/A

yes □ no □ N/A




regimen is too complex


yes □ no

yes □ no □ N/A

yes □ no □ N/A


too many pills

change to combination therapy


yes □ no

yes □ no □ N/A

yes □ no □ N/A


side effects

patient education/monitoring

add medication/regimen

discontinue medication/regimen

alter regimen/change drug due to safety

alter compliance or administration technique

other

yes □ no

yes □ no □ N/A

yes □ no □ N/A


forgets to refill

auto refill

text reminder/emails/phone call

delivery


yes □ no □ N/A

yes □ no □ N/A


transportation problems getting to pharmacy to pick up meds


yes □ no

yes □ no □ N/A

yes □ no □ N/A


no time to pick up meds


yes □ no

yes □ no □ N/A

yes □ no □ N/A


can’t afford


yes □ no

yes □ no □ N/A

yes □ no □ N/A


other:


yes □ no

yes □ no □ N/A

yes □ no □ N/A




In the past 3 months, please list each prescription picked up by the client

Prescription Refills

Medication

Dose

Frequency

# dispensed

Prescription start date

Refill due date*

Date refill picked up*

ART

























































Other (?)


















































*If there is more than 1 refill, for the same medication, in the past 3 months, list each refill due date and refill pick up date separately











Appendix 1: Therapy issues identified and suggested resolutions

For each therapy issue identified select a suggested resolution to record in the table under “suggested resolution”

Therapy issue identified

Suggested resolution

  1. Discrepancies found between multiple medication lists


    1. Consider discontinuing medication and starting_______

    2. Confirm which medication patient should be taking

    3. Confirm which dose of medication patient should be taking

    4. Confirm which dosing form patient should be taking

    5. Confirm which route patient should be taking

2. Drug interaction


2.1 Consider discontinuing medication

2.2 Consider discontinuing medication and starting_______

2.3 Consider changing dose of medication from_____to______

3. Insufficient dose/duration (based on age, kidney, liver, lab results, or health condition)


3.1 Consider discontinuing medication and starting_______

3.2 Consider changing dose of medication from_______ to _______

3.3 Other

4. Excessive dose/duration (based on age, kidney, liver, lab results, or health condition)


4.1 Consider discontinuing medication and starting_______

4.2 Consider changing dose of medication from_______ to _______

4.3 Other

5. Unnecessary therapy


5.1 Medication may be an unnecessary duplication with _______

5.2 Medication does not correspond with a known health condition

5.3 Other

6. Suboptimal drug therapy


6.1 Medication may not be appropriate based on patient age

6.2 Medication may not be appropriate based on patient health condition

6.3 Other

7. Adherence - Prescription refill history indicates over/underuse


7.1 Prescription refill history indicates patient is OVERUTILIZING medication

7.2 Prescription refill history indicates patient is UNDERUTILIZING medication

7.3 Other

8. Other drug therapy problem



9. Adherence - Patient self-reports over/underuse


9.1 Consider discontinuing and starting_______

9.2 Other

10. Administration technique


10.1 Consider changing medication to dosage form/device such as______

10.2 Other

11. Adverse drug reactions



11.1 Consider discontinuing medication

11.2 Confirm existence of side effect

Other

12. Cost efficacy management


12.1 Consider discontinuing medication and starting_____

12.2 Consider changing medication to a generic, such as_____

12.3 Consider patient for enrollment into medication assistance program

12.4 Other



































Appendix 2: Health conditions identified and suggested resolutions

For each health condition identified select a suggested resolution to record in the table under “suggested resolution”

Health Condition identified

Suggested resolution

  1. Needs therapy


    1. Confirm patient needs additional therapy for health condition and consider starting____

    2. Confirm patient needs additional therapy for health condition

    3. Other

  1. Suboptimal drug therapy


    1. May be a more effective medication option for health condition

    2. Other

  1. Complex drug therapy


    1. Patient has issues with self-monitoring of health condition

    2. Patient unable to manage taking current medication regimen for _____

    3. Other

  1. Over-the-counter therapy


    1. Patient taking an over-the-counter therapy that may not be indicated for his/her health condition

    2. Patient is overusing over-the-counter therapy

    3. Other

  1. Patient is not taking at least 3 active drugs to treat HIV infection (boosting agent, such as ritonavir or cobicistat, do not count toward the 3 active drug regimen)


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Patient is not on a DHHS preferred regimen or alternate regimen


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Patient is taking a single tablet regimen (e.g. Atripla, Complera, Stribild, Trizivir) and is also taking another antiretroviral


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Patient CD4 count performed within the last 12 months is below 200 cells/µL and patient is NOT taking appropriate prophylaxis


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Viral load has been conducted in last 6 months, levels are detectable, adherence assessment complete, and a plan has been developed with provider to perform intervention


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Patient is co-infected with HIV/HBV and is not on a preferred backbone of either tenofovir + emtricitabine or tenofovir + lamivudine


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. If CrCl drops to ≤ 60 mL/min, then make an assessment, plan, and contact clinic OR if CrCl drops ≥ 25% from baseline, then make an assessment, plan, and contact clinic


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Rise in LFTS


    1. If LFTs (ALT and/or AST) increase 1.25 – 2.5 times the upper limit of normal (grade 1) then make an assessment and plan

    2. If LFTs (ALT and/or AST) increase 2.6 – 5 times the upper limit of normal (grade 2), then make an assessment and plan and contact clinic directly

    3. If LFTs (ALT and/or AST) increase >5.1 times the upper limit of normal (grades 3 [5.1-10 x ULN] and 4 [>10 x ULN]) then make an assessment and plan and contact clinic immediately

  1. Patient is taking tenofovir and Serum Creatinine has not been evaluated in 6 months


    1. Contact prescriber to schedule test

    2. Patient has test scheduled on date_____

  1. ARV therapy is not synchronized to be filled on the same date


    1. Provided short fill

    2. Provided long fill

    3. Other

  1. Using sold dates, over the past 90 days has the patient been either without ARV's for 3 or more consecutive days OR 9 days total in the 90 day period.


    1. Consider discontinuing_____

    2. Consider discontinuing_____ and starting_____

    3. Consider starting_____

    4. Other

  1. Other.

















Appendix 3: Non-HIV health conditions identified

1. Alzheimer's Disease

 2. Arthritis

 3. Asthma

 4. Atrial Fibrillation

 5. Benign Prostatic Hyperplasia (BPH)

 6. Cancer

 7. Chronic Obstructive Pulmonary Disease (COPD)

 8. Depression

 9. Diabetes

 10. Esophagitis/Gastroesophageal reflux (GERD)

 11. Gout Unspecified

 12. Heart Failure, Unspecifed

 13. Hypercholesterolemia

 14. Hypertension

 15. Myocardial Infarction

 16. Osteoporosis

 17. Pain

 18. Parkinson’s Disease

 19. Recent Hospital Discharge

 20. Other (write in condition)

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-24

© 2024 OMB.report | Privacy Policy