Comprehensive Medication Management Note (Follow-Up)

Date/Time: [encounter date and time]

Pharmacist: [name, credentials]

Visit Type: [in-person / phone / video]

Referring/Collaborating Provider: [name, credentials] (Include only if applicable.)

(Use clear, nonjudgmental language. Attribute patient-reported information. Omit sections that do not apply. When expected data are unavailable, document their absence rather than omitting silently.)

Reason for Visit & Interval Summary

[Brief statement of CMM follow-up focus] (State the specific medication management focus in one concise phrase, e.g., "Follow-up: HTN medication titration" or "Follow-up: diabetes—A1c review and GLP-1 tolerance.")

[Interval summary since last CMM visit] (In 1–3 sentences, include date of last visit, key prior actions, any hospitalizations/ED visits, and medication changes made by other clinicians. For brief check-ins targeting a single parameter, limit to 1–2 lines.)

Subjective

(Document patient-reported information relevant to medication decisions.)

• [Symptom/condition trajectory: improved / worsened / stable] (Include timeframe and context relevant to medication decisions.)
• [Medication experience] (Perceived benefit, tolerability, side effects, administration challenges.)
• [Adherence assessment] (Actual use vs prescribed; missed dose patterns; reasons for non-adherence. If not assessed, state: "Adherence not assessed today.")
• [Access and affordability issues] (Insurance changes, copays, prior authorization needs, supply issues.)
• [Patient-reported self-monitoring data] (Home BP, glucose, weight, etc. with device type, values/ranges, and timeframe.)

Objective

(Include only objective data pertinent to current medication therapy decisions. Provide dates for each value.)

• [Vital signs with dates]
• [Relevant laboratory results with collection dates]
• [Other pertinent diagnostics affecting medication decisions] (If expected data unavailable, state "Not available" with reason or "Ordered today" with rationale.)

Medication List & Changes

[Current medication list or reference to EHR medication module] (Include relevant OTCs, supplements, and devices. Note actual use if different from prescribed.)

[Medication changes since last visit] (Started, stopped, or modified—include who made the change and rationale when known.)

[Allergies/intolerances updated today] (Include only if new or clarified this visit.)

Assessment

[Overall clinical status summary] (2–3 sentences summarizing current status and key changes since last visit.)

(Organize by problem/condition. Prioritize highest-risk issues first. Tag each MTP as new, ongoing, or resolved.)

[Problem/Condition]: [MTP status: new / ongoing / resolved]

• Goal/Target: [therapeutic goal or clinical target]
• Current regimen: [relevant medications for this problem]
• Response to therapy: [benefit, progress toward goal]
• Safety/Tolerability: [adverse effects, interactions, relevant labs]
• Adherence/Access: [adherence status, barriers]
• Assessment conclusion: [what needs to change or continue]

(Repeat for additional problems as applicable.)

Plan & Follow-Up

(Pair each plan to the corresponding problem in Assessment.)

[Problem/Condition]

• Medication plan: [continue / start / stop / change with exact regimen and brief rationale]
• Monitoring: [what to monitor, when, action thresholds if applicable]
• Adherence/access interventions: [simplification, cost assistance, prior auth steps]
• Patient education: [key counseling provided]
• Care coordination: [prescriber communications, referrals] (Include only if applicable.)
• Contingency: [conditional actions if pending results] (Include only if applicable.)

(Repeat for additional problems as applicable.)

Follow-Up

• Timeframe: [e.g., 2 weeks / 4–6 weeks]
• Mode: [in-person / phone / video]
• Purpose: [goals for next visit]
• Pre-visit requirements: [labs, logs, items to bring]
• Return precautions: [symptoms warranting earlier contact] (Include only if clinically indicated.)
• Disposition: [continuing CMM / discharged from CMM with follow-up responsibility assigned] (Include only if discharging from CMM.)

Signature

[Pharmacist name, credentials, contact information]

[Co-signature line] (Include only if required by protocol.)