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Comprehensive Medication Review (CMR) - Encounter Worksheet
Pharmacist Name
:
CMR Completed On
:
Patient Name
:
Age
:
Gender
:
CONDITIONS
Current Condition
:
Current Conditions
DRUG ALLERGY & SIDE EFFECTS
Drug
:
Reaction
:
Drug Allergies & Side Effects
MEDICATION PROFILE
Name/Strength/Dosage Form
:
Prescriber
:
SIG
:
Related Condition
:
Medications
REASON
ACTION
RESULT
LEVEL
RATIONALE & CLAIM DESCRIPTION
CMR - Complex Drug Therapy (100)
Comprehensive Med Review (CMR) (200)
CMR - Drug Therapy Problems Identified (300)
CMR - No Drug Therapy Problems Identified (301)
Patient Refused (380)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Cost Effective Alternative (105)
Prescriber Consultation (205)
Patient Consultation (215)
Initiated Cost Effective Drug (305)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Patient Refused (Prescriber) (380)
Patient Refused (Patient) (380)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
New/Changed Prescription Therapy (110)
Patient Education and Monitoring (210)
Patient Education
Initial Consulation Date:
Topics Discussed:
Name of Drug
Therapeutic Class
Directions for Use
Side Effects/Warnings
Storage Requirements
Missed Dose Actions
Written Material
Set Monitoring Appointment
Monitoring
Follow-up Date:
Is the patient satisfied with the therapy?
YES
NO
Did the symptoms improve?
YES
NO
Where there any adverse reactions reported?
YES
NO
Is the patient adherent with therapy?
YES
NO
Therapy Success (i.e. resolved/stable) (310)
Therapy Failre (i.e. unresolved/worse) (320)
Patient Refused (380)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
New/Changed OTC Therapy (117)
Patient Education and Monitoring (210)
Patient Education
Initial Consulation Date:
Topics Discussed:
Name of Drug
Therapeutic Class
Directions for Use
Side Effects/Warnings
Storage Requirements
Missed Dose Actions
Written Material
Set Monitoring Appointment
Monitoring
Follow-up Date:
Is the patient satisfied with the therapy?
YES
NO
Did the symptoms improve?
YES
NO
Where there any adverse reactions reported?
YES
NO
Is the patient adherent with therapy?
YES
NO
Therapy Success (i.e. resolved/stable) (310)
Therapy Failre (i.e. unresolved/worse) (320)
Patient Refused (380)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
New/Needs Immunization (118)
Patient Consultation (215)
Immunization Administered by Pharmacist (318)
Patient Refused (380)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Drug Therapy Problem (DTP) Detected
Indication - Needs Drug Therapy (120)
Prescriber Consultation (205)
Initiated New Therapy (330)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Indication - Unnecessary Prescription Therapy (125)
Prescriber Consultation (205)
Discontinued Therapy (335)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Efficacy - Suboptimal Drug (130)
Prescriber Consultation (205)
Changed Drug (340)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Efficacy - Dose Too Low (135)
Prescriber Consultation (205)
Increased Dose (345)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Safety - Adverse Drug Reaction (140)
Prescriber Consultation (205)
Discontinued Therapy (335)
Decreased Dose (355)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Safety - Drug Interaction (145)
Prescriber Consultation (205)
Discontinued Therapy (335)
Increased Dose (345)
Decreased Dose (355)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Safety - Dose Too High (150)
Prescriber Consultation (205)
Decreased Dose (355)
Prescriber Refused Reccomendation (375)
3 Attempts Unable to Reach Prescriber (378)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Adherence - Overuse of Medication (155)
Patient Adherence Consultation (215)
Date non-adherence was identified:
Determine Barriers to Adherence
Concerned about potential side effects
Decreased cognitive function
Experienced side effects
Feels medication is not helping
Feels medication is not needed
Forgets to take on non-routine days
Forgets to take on routine days
Limitations on activities of daily living
Medication cost is too high
No barrier identified
Patient taking differently than written directions
Refill request delay
Too many medications or doses per day
Transportation limitations prevent pharmacy access
Education
Set Monitoring Appointment
Date non-adherence was resolved:
Altered Adherence (360)
Altered Administration or Technique (365)
Patient Refused (380)
3 Attempts Unable to Reach Patient (379)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Adherence - Underuse of Medication (160)
Patient Adherence Consultation (215)
Date non-adherence was identified:
Determine Barriers to Adherence
Concerned about potential side effects
Decreased cognitive function
Experienced side effects
Feels medication is not helping
Feels medication is not needed
Forgets to take on non-routine days
Forgets to take on routine days
Limitations on activities of daily living
Medication cost is too high
No barrier identified
Patient taking differently than written directions
Refill request delay
Too many medications or doses per day
Transportation limitations prevent pharmacy access
Education
Set Monitoring Appointment
Date non-adherence was resolved:
Altered Adherence (360)
Altered Administration or Technique (365)
Patient Refused (380)
3 Attempts Unable to Reach Patient (379)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Adherence - Inappropriate Admin/Technique (165)
Patient Adherence Consultation (215)
Date non-adherence was identified:
Determine Barriers to Adherence
Concerned about potential side effects
Decreased cognitive function
Experienced side effects
Feels medication is not helping
Feels medication is not needed
Forgets to take on non-routine days
Forgets to take on routine days
Limitations on activities of daily living
Medication cost is too high
No barrier identified
Patient taking differently than written directions
Refill request delay
Too many medications or doses per day
Transportation limitations prevent pharmacy access
Education
Set Monitoring Appointment
Date non-adherence was resolved:
Altered Adherence (360)
Altered Administration or Technique (365)
Patient Refused (380)
3 Attempts Unable to Reach Patient (379)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
Adherence - Predicted Non-Adherence (170)
Patient Adherence Consultation (215)
Initial Consulation Date:
Follow-up Date:
Maintained Adherence (360)
Patient Refused (380)
3 Attempts Unable to Reach Patient (379)
Indicate Severity Level:
Click to Select
Level 1 - Adherence Support
Level 2 - Reduced Drug Costs
Level 3 - Prevented a Physician Visit
Level 4 - Prevented Additional Prescription Order
Level 5 - Prevented Emergency Room Visit
Level 6 - Prevented Hospital Admission
Level 7 - Prevented a Life Threatening Situation
Please document rationale for assigned severity level and describe claim details.
CLEAR Entries:
Click to Select
Patient Information
Current Conditions
Drug Allergies & Side Effects
Medications
CMR - Complex Drug Therapy (100)
Cost Effective Alternative (105)
New/Changed Prescription Therapy (110)
New/Changed OTC Therapy (117)
New/Needs Immunization (118)
Indication - Needs Drug Therapy (120)
Indication - Unnecessary Prescription Therapy (125)
Efficacy - Suboptimal Drug (130)
Efficacy - Dose Too Low (135)
Safety - Adverse Drug Reaction (140)
Safety - Drug Interaction (145)
Safety - Dose Too High (150)
Adherence - Overuse of Medication (155)
Adherence - Underuse of Medication (160)
Adherence - Inappropriate Admin/Technique (165)
Adherence - Predicted Non-Adherence (170)
Clear All Entries