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MTM Encounter -
Standardized Patient Written Documentation
Cover Letter (CL)
Date of Letter
:
Prefix:
Click to Select
Mr.
Mrs.
Ms.
None
Patient's Full Name:
Patient's Address:
Date CMR Performed
:
Pharmacist's Full Name
:
Cover Letter (CL)
[DATE OF LETTER]
[PREFIX]
[PATIENT NAME]
[PATIENT ADDRESS]
Dear
[PREFIX]
[PATIENT NAME]
,
Thank you for talking with me on
[DATE OF CMR]
about your health and medications. This MTM (Medication Therapy Management) program helps you make sure that your medications are working.
Along with this letter are an action plan (Medication Action Plan) and a medication list (Personal Medication List).
The action plan has steps you should take to help you get the best results from your medications. The medication list will help you keep track of your medications and how to use them the right way.
Have your action plan and medication list with you when you talk with your doctors, pharmacists, and other healthcare providers.
Ask your doctors, pharmacists, and other healthcare providers to update them at every visit.
Take your medication list with you if you go to the hospital or emergency room.
Give a copy of the action plan and medication list to your family or caregivers.
If you want to talk about this letter or any of the papers with it, please call Dr.
[PHARMACIST NAME]
at 1-800-555-0123 between the hours of 9am and 5pm, Monday through Friday. I look forward to working with you and your doctors to help you stay healthy.
Sincerely,
[PHARMACIST NAME]
, PharmD
Medication Action Plan (MAP)
Add Action Plan #: (max is 15)
Click to Select
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What we talked about
:
What I need to do
:
Medication Action Plan (MAP)
Medication Action Plan
for
[PREFIX]
[PATIENT NAME]
Date Prepared:
[DATE OF LETTER]
This action plan will help you get the best results from your medications if you:
Read "What we talked about."
Take the steps listed in the "What I need to do" boxes.
Fill in "What I did and when I did it."
Fill in "My follow-up plan" and "Questions I want to ask."
Have this action plan with you when you talk with your doctors, pharmacists, and other healthcare providers. Share this with your family or caregivers too.
My follow-up plan
(add notes about next steps):
Questions I want to ask
(include topics about medications or therapy):
Click to Select
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Personal Medication List (PML)
Allergies or side effects
:
Add Medication #: (max is 15)
Click to Select
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Medication (name, strength, dosage form)
:
How I use it
:
Why I use it
:
Prescriber
:
Notes
:
Personal Medication List (PML)
Personal Medication List
for
[PREFIX]
[PATIENT NAME]
Date Prepared:
[DATE OF LETTER]
This medication list was made for you after we talked.
Use blank rows to add new medications. Then fill in the dates you started using them.
Cross out medications when you no longer use them. Then write the date and why you stopped using them.
Ask your doctors, pharmacists, and other healthcare providers to update this list at every visit.
Keep this list up-to-date with:
prescription medications
over the counter drugs
herbals
vitamins
minerals
If you go to the hospital or emergency room, take this list with you. Share this with your family or caregivers too.
Click to Select
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MTM Encounter -
Comprehensive Medication Review (CMR)
-
Detailed Documentation
Pharmacist Name
:
CMR Completed On
:
Was a written Patient Takeaway provided to the patient
?
Yes
No
Patient Name
:
Age
:
Gender
:
Is patient cognitively impaired
?
No
Yes
PROBLEM (REASON)
ACTION
RESULT
SEVERITY 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)
Unable to Reach Prescriber After 3 Attempts (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 Failure (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.
Needs Immunization (121)
Prescriber Consultation (205)
Immunization Administered (331)
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)
ACTION
RESULT
SEVERITY LEVEL
RATIONALE & CLAIM DESCRIPTION
Indication -
Needs Drug Therapy (120)
Prescriber Consultation (205)
Initiated New Therapy (330)
Prescriber Refused Reccomendation (375)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Prescriber After 3 Attempts (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)
Unable to Reach Patient After 3 Attempts (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)
Unable to Reach Patient After 3 Attempts (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)
Unable to Reach Patient After 3 Attempts (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)
Unable to Reach Patient After 3 Attempts (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