Model Pharmacy Exam - Practice Prescription

1. Verification of Patient Demographics

Verify the patient’s name and correct spelling
Obtain the following information:

▢  Age: __________

▢  Date of Birth: __________

▢  Gender (at birth): __________

▢  Address: ____________________

▢  Telephone #: ____________________

2. Verification of Insurance Coverage

Ask (new pt.)/Verify (existing pt.) whether patient has a
prescription insurance card, coupon, or will be paying cash.

✔ Cash ▢ Third Party/Coupon

Member Name: ___________ Person Code: __________
Member ID: __________ Rx Group: __________
Rx BIN: __________ Rx PCN: __________

3. Verification of Patient Health Information

Ask/Verify if patient has allergies to any medications
Ask/Verify if patient has any chronic conditions

▢ Allergies: ______________________________

▢ Chronic Illness: ______________________________

4. Verification of Safety Cap Preference

Ask/Verify whether patient requests no safety caps.
If yes, stamp the back of the Rx with safety cap waiver and have patient sign.

Safety Caps? ✔ YES ▢ NO

5. Verification of Will Call Time

Ask if the patient will wait for prescription, pick up at a later time, or have it delivered.
Provide a wait time (1 hour) if the patient indicates they'll wait for the prescription.

Delivery Status: ✔ Waiting ▢ Pickup ▢ Delivery

Controlled Substance Documentation - Write on Rx Hardcopy

▢ CII/CIII/CIV = 1) patient address, 2) prescriber address, 3) prescriber DEA#

▢ CII Only = cancel Rx (draw line lower left to upper right, sign name & date)

Drug Utilization Review (DUR)

▢ NO ERRORS and NO PRESCRIBER CONTACT

▢  Drug Dosing Error

▢  Drug Allergy/Contraindication

▢  Drug-Drug Interaction

Summary (with Sig Rating for DI):

Management:

Proposed Change:

▢  Dose Increase

▢  Dose Decrease

▢  Avoid Drug or Drug Combination

▢  Alter Drug Administration