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Pharmskills Online - MTM Standardized Patient Written Documentation

MTM Encounter - Standardized Patient Written Documentation

 
 
 
 
 Cover Letter (CL)

 
Date of Letter:
 
Prefix:
 
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)

Select Problem Code:
 

 
What we talked about:

 
What I need to do:

 
Add Action Plan #: (max is 15)
 

 
 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):
 
 

 

 
 
 
 
 Personal Medication List (PML)

Allergies or side effects:

 

 
 
 
Add Medication #: (max is 15)
 
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.
 

 


 
MTM Encounter - Comprehensive Medication Review (CMR) - Detailed Documentation

 
 

 
 
 
 
 
 
 

 
 
 
 

Pharmacist Name:       CMR Completed On:       Was a written Patient Takeaway provided to the patient?  
 
 
Patient Name:       Age:       Gender:       Is patient cognitively impaired?  
 
PROBLEM (REASON)
ACTION
RESULT
SEVERITY LEVEL
RATIONALE & CLAIM DESCRIPTION

 

 

 
DRUG THERAPY PROBLEM (DTP)
ACTION
RESULT
SEVERITY LEVEL
RATIONALE & CLAIM DESCRIPTION
Indication - Needs Drug Therapy (120)
Efficacy - Suboptimal Drug (130)
Efficacy - Dose Too Low (135)
Safety - Drug Interaction (145)
Safety - Dose Too High (150)
Adherence - Overuse of Medication (155)

 

 

 

 

CLEAR Entries:     


 
Perform an MTM Intervention
 
INSTRUCTIONS:
  1. Complete a Comprehensive Medication History (CMH) Interview Form - Click HERE

    • DATA COLLECTION
    • Pharmacist Documentation
      • Listen to the patient interview.
      • Fill out the CMH interview form while listening to the interview.

  2. Complete a Comprehensive Medication Review (CMR) Worksheet - CLICK HERE

    • DATA ANALYSIS
    • Pharmacist Documentation
      • Complete ALL sections of this worksheet.
      • It is intended to help guide the pharmacist in analyzing patient data gathered during the CMH interview.

  3. Complete all three Patient Documentation Forms and submit electronic CMR documentation - CLICK HERE

    • DATA REPORTING
    • Patient Documentation
      • Reimbursement for pharmacist services requires the patient be given:
        1. Cover Letter (CL)
        2. Medication Action Plan (MAP)
        3. Personal Medication List (PML).
    • Complete the electronic CMR documentation and print a hard copy.