Summative medication review proforma

Summative medication review proforma
Data to be taken from the patient’s medication record (in community pharmacy) or from the patient’s medication chart/prescription or notes (in hospital pharmacy).
You should select patients who are taking at least 3 medicines (maximum of 5).
Student name: Ali Dobia
Patient age – 50 Sex M/F – Female Allergies and brief description of allergic reaction:
NKA
Weight (if applicable; approximate if not available) 60kg Height (if applicable; approximate if not available) 165c m
Medication list
List medications and doses including those taken as required Medical condition(s) (if known)
Glucophage (Metformin) – 500 mg twice a day.
Lovastatin- (Altocor) 20 mg once a day
Lantus (Insulin glargine)- once a day at the same time each day
Identify the pharmacology, major side effects and contraindications, parameters to monitor for effectiveness, and counselling points and other information that would be helpful to patients.
Name of medicine (as listed earlier) Pharmacology (mechanism of action) Major side effects Major contra-indications Parameters to monitor for effectiveness (both patient and drug parameters) Summarise counselling points for each drug
Any other information that would be helpful to patients e.g. diaries, information cards, websites

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Identify the potential drug-related problems and pharmaceutical care needs

Name of medicine Identify potential drug-related problems Pharmaceutical Care needs (what are they and action needed)
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