CMR Patient Summary (Cover Letter, Personal Medication List, and Medication Action Plan)

Comprehensive Medication Review (CMR) Summary Packet

(Use plain language with "you/your," active voice, and short sentences. Avoid medical abbreviations and Latin directions. Spell out times of day and frequencies, such as "in the morning" or "twice a day.")

MTM Provider/Organization: [MTM provider/organization]

Pharmacist Name and Credentials: [Pharmacist name and credentials]

Contact Information: [Phone, secure message, and/or email]

Patient Name: [Patient name]

Date of Birth: [Date of birth]

Date CMR Performed: [Date CMR performed]

Date Prepared: [Date prepared]

Cover Letter

Dear [Patient name],

Thank you for completing your medication review. We reviewed all your medicines to help you stay safe and get the best results.

This packet includes your To-Do List (next steps) and your Medication List.

• Bring the To-Do List to your next doctor visit.
• Bring the Medication List to every appointment, hospital visit, or emergency room visit.
• Ask your providers to update the list when changes are made.

Safety: Do not stop or start prescription medicines without talking to your doctor first. Call 911 for emergencies. [Specific safety concern and when to call] (Only include if a specific safety concern was discussed. Use one clear sentence.)

[Follow-up plan] (State the plan for follow-up, such as who will call whom and when. Only include scheduled check-ins or lab work if confirmed.)

If you have questions, contact [Pharmacist name] at [Contact information]. [Office hours or best times to call] (Only include if provided.)

Recommended To-Do List

Medication Action Plan

Patient: [Patient name] | Date: [Date prepared]

Bring this list when you go to the doctor. Share it with your family or caregivers.

What We Talked About	What I Should Do
[Topic or issue 1]	[Action 1] (Start with a verb: Call, Ask, Schedule, Monitor, Bring. If prescriber approval is needed, write "Ask your doctor" or "Call Dr. [Name] to discuss." Label medication changes as recommendations unless confirmed.)
[Topic or issue 2]	[Action 2]
[Topic or issue 3]	[Action 3]
[Topic or issue 4]	[Action 4]
[Topic or issue 5]	[Action 5]

(Include 3–5 action items. Prioritize safety risks first, then high-impact clinical issues, then adherence or cost concerns. Remove unused rows.)

My Notes and Questions:

[Leave blank space for patient notes]

Medication List

Personal Medication List

Patient: [Patient name] | Date: [Date prepared]

Bring this list to the doctor, hospital, or emergency room. Share it with your family or caregivers.

Medication (name, strength, form)	How I Take It	Why I Use It	Prescriber
[Medication 1: generic name (brand), strength, form]	[Directions 1] (Use plain language and time of day. For as-needed medicines, include purpose and maximum frequency. Add "Please verify" if information is uncertain.)	[Indication 1] (Use simple terms patients understand.)	[Prescriber 1] (Write "Self" for over-the-counter if appropriate.)
[Medication 2: generic name (brand), strength, form]	[Directions 2]	[Indication 2]	[Prescriber 2]
[Medication 3: generic name (brand), strength, form]	[Directions 3]	[Indication 3]	[Prescriber 3]
[Medication 4: generic name (brand), strength, form]	[Directions 4]	[Indication 4]	[Prescriber 4]
[Medication 5: generic name (brand), strength, form]	[Directions 5]	[Indication 5]	[Prescriber 5]
(Add rows as needed for all current prescriptions, over-the-counter medications, vitamins, supplements, and non-oral therapies such as inhalers, patches, and eye drops.)

(Leave 2–3 blank rows for patient additions. Instruct: "Add new medicines or cross out medicines you no longer take.")

Allergies: [List any allergies and reactions] (If none reported, write "No known allergies.")

Side Effects I Have Had: [List side effects and which medicine caused them]

My Notes: [Blank space for patient notes]

Medication Disposal

(Only include this section if safe disposal counseling was discussed or required by the program.)

• Use a pharmacy take-back program when possible. Ask your pharmacy or local government about locations and events.
• If a take-back option is not available, follow any disposal instructions on the label or patient guide.
• If there are no instructions, mix medicines (do not crush) with coffee grounds or cat litter, seal in a bag, and place in household trash.
• Scratch out or remove personal information from empty bottles before discarding.