ZUMBRO HOUSE

MEDICATION ASSESSMENT

Person Receiving Services (Name):______

Medication Self-Management

  1. Number of different medications taken/day: _____ Number of dosage times/day: ____
  2. Cognitive Status: ______
  3. Functional Limitations: ______
  4. History of Noncompliance: ______
  5. Is the home environment sanitary: ___ No ___ Yes

If No, describe: ______

  1. Client knowledgeable regarding the medication regimen? ___ No ___ Yes

If No, describe education/resources provided and on-going needs:

____Medication reminders

____Central storage of medication

____Progress as Tolerated to self punching of medications

____Provide education on medication name, indications for use and side effects

____Observe swallowing of medication

What assistance with Medication Self- Management is required based on assessment?

all that apply:

___ Medication Set Up

___ Medication Administration

___ Coordination of Medications

___ Education with the Person Receiving Services

___ Housekeeping/Cleaning Support

Diversion of Medications

  1. Is there “street value” of medications being used by individual? ____ No ____ Yes

If Yes, describe: ______

  1. Is the individual’s residence in a high risk location? ____ No ____ Yes

If Yes, describe: ______

  1. Number of residents or visitors to the home with access to medications: ______
  2. Other risk factors/protection of medications: ______

______

Potential for diversion of medication: ___ Low ___ Medium ___ High

(High risk: presence of 3-4 of the criteria, moderate risk: presence of 2-3 criteria, low risk: presence of 0-1 criteria)

Plan to address the risk:

all that apply:

___ Continue to Monitor

___ Secure Medications (describe): ______

___ Other (describe): ______

Individual’s Visits Away from Home

  1. How often does the individual leave the home? ______
  2. How long is the individual gone and over what periods of time? ______
  3. Are the trips generally: ___ Planned ___ Unplanned

Is a medication management plan needed when the individual is away from home?

____ No ____ Yes

If Yes, describe: ______

Medication Reconciliation

Yes / No / Plan to Address / NA
Is there a purpose identified for each medication?
Is the drug therapy effective?
Are the immediate desired effects of the medications evident?
Are side effects present?
Are any unusual or unexpected effects present?
Yes / No / Plan to Address / NA
Were any actual or potential drug interactions identified?
Is there duplicate drug therapy?
Is any drug therapy currently associated with laboratory monitoring?
Are any allergic reactions present?
Are there changes in condition that contraindicate continued administration of the medications?
Other (specify):

Coordination with other providers completed as a result of the medication reconciliation:

all that apply:

___ Primary Care Provider

___ Pharmacy

___ Interdisciplinary Team (Guardian, Case Manager, Other Service Provider)

___ Other (specify): ______

Comment: ______

______

______

RN Signature:______Date:______

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