AmbulatoryCare/Community PracticePatientInterventions

Field Encounters

Age of Patient: Years

Gender: MaleFemale

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Adherence counseling / Medication reconciliation
Administration or technique counseling / Medication/disease counseling
ADR identified or intervention / MTM or Complete medication review
Allergy prevented / Pharmacokinetic evaluation
Antibiotic recommendation / Pharmacy calculation
Blood glucose management / Pharmacy consultation
Cost avoidance or insurance intervention / Patient assistance program enrollment
Dose adjustment or recommendation / Prior authorization obtained
Drug Information provided / Therapeutic drug monitoring
Drug-food interaction identified or prevented / Therapeutic duplication avoided
Drug-drug interaction identified or prevented / Therapeutic substitution
Electrolyte replacement recommendation / Vaccine administration
High risk medication identified or prevented / Vaccine adverse effect reported (VAERS)
Lab recommendation / Vaccine recommendation
Medication history obtained / Other
Medication recommended
Comments:

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Ambulatory Care/Community Practice Patient Interventions

Field Encounters

Age of Patient: Years

Gender: MaleFemale

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Adherence counseling / Medication reconciliation
Administration or technique counseling / Medication/disease counseling
ADR identified or intervention / MTM or Complete medication review
Allergy prevented / Pharmacokinetic evaluation
Antibiotic recommendation / Pharmacy calculation
Blood glucose management / Pharmacy consultation
Cost avoidance or insurance intervention / Patient assistance program enrollment
Dose adjustment or recommendation / Prior authorization obtained
Drug Information provided / Therapeutic drug monitoring
Drug-food interaction identified or prevented / Therapeutic duplication avoided
Drug-drug interaction identified or prevented / Therapeutic substitution
Electrolyte replacement recommendation / Vaccine administration
High risk medication identified or prevented / Vaccine adverse effect reported (VAERS)
Lab recommendation / Vaccine recommendation
Medication history obtained / Other
Medication recommended
Comments:

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Ambulatory Care/Community Practice Patient Interventions

Field Encounters

Age of Patient: Years

Gender: MaleFemale

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Adherence counseling / Medication reconciliation
Administration or technique counseling / Medication/disease counseling
ADR identified or intervention / MTM or Complete medication review
Allergy prevented / Pharmacokinetic evaluation
Antibiotic recommendation / Pharmacy calculation
Blood glucose management / Pharmacy consultation
Cost avoidance or insurance intervention / Patient assistance program enrollment
Dose adjustment or recommendation / Prior authorization obtained
Drug Information provided / Therapeutic drug monitoring
Drug-food interaction identified or prevented / Therapeutic duplication avoided
Drug-drug interaction identified or prevented / Therapeutic substitution
Electrolyte replacement recommendation / Vaccine administration
High risk medication identified or prevented / Vaccine adverse effect reported (VAERS)
Lab recommendation / Vaccine recommendation
Medication history obtained / Other
Medication recommended
Comments:

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Ambulatory Care/Community Practice Patient Interventions

Field Encounters

Age of Patient: Years

Gender: MaleFemale

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Adherence counseling / Medication reconciliation
Administration or technique counseling / Medication/disease counseling
ADR identified or intervention / MTM or Complete medication review
Allergy prevented / Pharmacokinetic evaluation
Antibiotic recommendation / Pharmacy calculation
Blood glucose management / Pharmacy consultation
Cost avoidance or insurance intervention / Patient assistance program enrollment
Dose adjustment or recommendation / Prior authorization obtained
Drug Information provided / Therapeutic drug monitoring
Drug-food interaction identified or prevented / Therapeutic duplication avoided
Drug-drug interaction identified or prevented / Therapeutic substitution
Electrolyte replacement recommendation / Vaccine administration
High risk medication identified or prevented / Vaccine adverse effect reported (VAERS)
Lab recommendation / Vaccine recommendation
Medication history obtained / Other
Medication recommended
Comments:

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown