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Pharmacist Notes Consent to provided extension given by the patient themselves in person Plans to see prescriber: Prescriber typically gives (qty and refills): Indication(s): Patient has been taking medication for: AE:
Share Accessed: Not accessed due to time restraint Duration rational: long term medication with no red flags found Other notes: Choosing not to fax PCP given consistency in therapy.

SERVICE OFFERS (ACCEPTED/DECLINED/CONSIDERING & DATE) MedSync: Medication Review: Disease Man. Prog: Bloom Program: Minor Ailments Awareness if app ( ): Depo-Provera inj: B12: Shingles: HPV Vaccine: Hepatitis Vaccines: Travel Consult: Take Home Naloxone:

Topic: Tylenol #1 Assessment performed on 2023 Allergies, Conditions, and Dr updated on profile. Indication/Reason for use: Last fill date of Tylenol #1: Rx drugs used for pain: Non Rx drugs used for pain (Are NSAIDs possible): Go over ingredient list and max dose Potential for addiction/dependence Potential for liver damage with long term usage. Possibility for ADRs constipation, drowsiness, impairment etc. For personal usage only Other notes (May need Rx from prescriber etc):

Advanced Medication Review Service

Checklist: Before apt: Find someone who meets all criteria: Covered by seniors pharmacare. Must not have had med review in last fiscal year. Patient must agree that they are suitable candidate. (Check service offering to see if already asked) Not reside in nursing/special care home. Be taking 4 or more prescription medications; OR taking one of the following: Methyldopa, Indomethacin, Cyclobenzaprine, Diazepam, Chlordiazepoxide,Clorazepate, Amitriptyline. Have at least one of the following diseases: Asthma, Diabetes, Hypertension, Hyperlipidemia, CHF, COPD, Arthritis Patients must bring all meds Rx, OTC, supplements, creams, inhalers etc. Call and give pitch: Hello (name) I’m calling to see if you would be interested in an Advanced Med Review. Did you have a minute for me to explain what an advance med review is? You will sit down with a pharmacist for up to an hour and we will go over your medications, conditions, blood work, vaccines and more.
We will make sure your pharmacy profile is up to date. We will do our best to address any questions you might have. At the end, we give a printed sheet of all the medications and if there are any issues, we can address them with your doctor With your drug plan there is no charge for the service. Is this something you’d be interested in? If yes: It is very important you bring your medications including Rx, OTC, supplements, creams, inhalers, eye drops etc. so that we have a complete picture of your medication. We will give you a call the day before your appointment to remind you of your appointment. Update Service offering note (accepted/rejected + date) Insert appointment in Kroll calendar Setup a note for assistant to call the day before and remind them to bring their meds Print Detailed Medical History Report and lab data for last 365 days Print off a blank advanced med review form Put all meds through lexi interaction checker and print Look at one specific medication and look at adherence Start a advanced med review on kroll and copy and paste into pharmacists/general comments In person: Update kroll profile (phone, address, drug plans, conditions) Go over first page of Med Review form Check blood pressure (and blood glucose) - record in charting Drug interaction report Blood work Adherence (Blister packing warranted?) Go through each condition: Print 2 copies of the Medication Review Medication List and have the patient and pharmacist sign the pharmacist’s copy and the pharmacist sign the patient copy Bill AMRS using PIN 9389999999. Exception code ED. Special Auth code 91 (In person) Special service Code 006. Fee=150 Schedule a follow up if warranted Create a note to make sure any issues sent to Dr have been addressed.

Copy and Paste to Pharmacists Comments

Demographics/Lifestyle: Living Arrangements/Family: Who takes care of medications: Themselves Smoker: No (0 per day) Alcohol: (drinks per week) Caffeine: (cups per day) Recreational drug(s) used: Notes:

Vaccines: *Influenza: Last dose: *COVID: Last dose: TDAP: (every 10 years): Pneumococcal: Shingles: Hepatitis A+B:

Adherence: Do you ever forget to take your medications: Do you ever forget whether or not you already took your medications? Sometimes when you feel worse do you ever stop taking your medication? When you feel better do you stop taking your medication? Do you ever not take medication because of cost? *Adherence based on billing shows that patient takes medication ___% of the time

Drug Interactions: *Lexicomp drug interaction report shows the following concerns:

Condition: Medications used: Disease control (patient status and perspective/Tx/Labs): ADRs: Disease complications: Impression/assessment (DTP): Plan/Recommendation/Monitoring:

Other Labs *Kidney Function: eGFR= as of (date) *Liver disease:

Full documentation (including lab results) placed in documents

Copy and Paste into General Comments

Major drug therapy problem that would warrant follow-up:

Minor drug therapy problems identified:

Other notes

Narcotic/Benzo Count Template:

1. Drug Name mg (manufacturer) DIN On (date+counter’s name) counted: #, Kroll inventory says we should have #, making us # short/over On (date+counter’s name) counted: #, Kroll inventory says we should have #, making us # short/over On (date+counter’s name) counted: #, Kroll inventory says we should have #, making us # short/over

Drug Utilization Audit report from date of last count to today’s date found the following patients are taking the drug: Names Billing was checked for the above patients from the last count to today and the following discrepancies were found: Discrepancies/none Is there anything in the kroll workflow: Yes/No Anything recently destroyed or put at the bottom of the safe since the last count: Yes/No Last Benzo/narcotic count count: Short/Surplus Was inventory properly adjusted last time? yes/no Kroll inventory changed: Incomplete

Summary: Will/ Will not be sending report sent to Health Canada given the medication is over/under

How to bring up Narcotic/Benzo list on kroll: Reports→Drug→Drug Inventory listing report→ Change schedule (targeted or narcotic/controlled)

Back Count Alert Note

• Copy and paste into drug comment field and have it allerted for packaging and verify Rx packaging This medication needs to be back counted Step 1 - Type Ctrl+PrtScrn in order to print these instructions Step 2 - Double Count the medication and document as usual Step 3 - Set the DC pills aside count everything else in pharmacy Step 4 - Press F5 to see what inventory should be. Step 5 - If accurate document: Back count accurate (Date + initials) Step 6 - If not accurate count it again Step 7 - If still not accurate send a kroll email to Tim with the drug, kroll inventory, your count, the date.