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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)
  Cost Effective Alternative (105)

 
  New/Changed Prescription Therapy (110)

 
  New/Changed OTC Therapy (117)

 
  New/Needs Immunization (118)
Drug Therapy Problem (DTP) Detected
  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 Entries: