Comprehensive Medication Management Note (Initial Assessment)

Note Type: Comprehensive Medication Management Note (Initial Assessment)

Encounter Date/Time: [Encounter date and time]

Setting/Modality: [in-person / video / phone]; [Clinic or site name]

Participants: [Patient name or initials]; [Caregiver(s) if present]; [Interpreter used: yes/no; language if applicable]

Author: [Pharmacist name, credentials]

Referral Source: [Referring clinician or service]

Reason for Referral: [Referral question or concern]

Primary Care Provider: [Name, specialty]

Preferred Pharmacy: [Pharmacy name, location, contact]

Reason for Visit and Patient Goals

(Use 2–6 concise bullets. Include direct quotes for impactful patient-stated goals. Patient goals are required for initial CMM encounters.)

• [Chief concern or referral question]
• [Patient-stated goal(s) in their own words]
• [Medication-related concerns: side effects, cost/access, regimen confusion, adherence challenges]
• [Specific outcomes patient prioritizes: symptom relief, lab/vital targets, quality-of-life measures]
• [Other expectations or preferences relevant to therapy decisions]

Medication Experience and Relevant History

(Format as 1–2 short paragraphs. Attribute sources for key facts: patient-reported, caregiver, EHR, pharmacy fill history, external records.)

[Narrative summary of medication experience including perceived benefits/harms, prior successes/failures, preferences/beliefs about medicines, adherence patterns and timing, missed doses, administration technique; use of adherence aids; access/cost/coverage barriers including copays, formulary, prior authorization needs; relevant social factors impacting medication outcomes.]

[Brief summary of active medical problems relevant to medication decisions; recent hospitalizations/ED visits; pregnancy or lactation status if applicable.]

Allergies, Intolerances, and Adverse Reactions

(List each agent on a separate line. Distinguish allergy vs intolerance vs side effect. If reaction unknown, document explicitly with plan to clarify.)

• [Agent] — [Allergy / Intolerance / Side effect]; Reaction: [reaction]; Severity: [mild / moderate / severe]; Onset: [approximate date or period]; Re-challenge: [yes / no / unknown]; Source: [patient / EHR / caregiver / pharmacy]
• [Additional agents as applicable]

Current Medication List (Reconciled)

Medication Reconciliation Statement: Reconciliation performed using: [patient interview / medication bottles / EHR medication list / pharmacy fill records / claims data / discharge summary / caregiver report]. Discrepancies identified: [list each with source and resolution status, or "none identified"]. Pending verifications: [items requiring confirmation and plan to obtain, or "none"].

Prescription Medications

Medication (generic; brand if relevant)	Strength/Dose	Route	Frequency/Schedule	Indication	How Patient Actually Takes It	Prescriber	Monitoring Notes
[Medication name]	[Strength/Dose]	[Route]	[Frequency/Schedule]	[Indication]	[Actual use; adherence notes; PRN usage; timing]	[Prescriber]	[Monitoring needs; safety concerns; access issues]

OTC / Nonprescription

(If none, document "None reported.")

Medication	Strength/Dose	Route	Frequency/Schedule	Indication	How Patient Actually Takes It	Prescriber	Monitoring Notes
[Medication name]	[Strength/Dose]	[Route]	[Frequency/Schedule]	[Indication]	[Actual use/adherence]	[Prescriber or N/A]	[Monitoring/access notes]

Supplements / Herbals

(If none, document "None reported.")

Product	Strength/Dose	Route	Frequency/Schedule	Indication/Purpose	How Patient Actually Takes It	Prescriber	Monitoring Notes
[Product name]	[Strength/Dose]	[Route]	[Frequency/Schedule]	[Indication/Purpose]	[Actual use/adherence]	[Prescriber or N/A]	[Monitoring/access notes]

Pertinent Objective Data

(Include most recent values first with dates and sources. If key data unavailable, document what was ordered/requested.)

• Vital signs: [BP, HR, weight/BMI] — Source: [clinic / home device]; Date: [date]. [Home readings summary if provided]
• Renal function: [SCr, eGFR] — Date: [date]
• Electrolytes: [Na, K, Mg, Ca] — Date: [date]
• Hepatic function: [AST, ALT, ALP, Tbili, Albumin] — Date: [date]
• Glycemic control: [A1c]; [SMBG/CGM summary if available] — Date: [date]
• Lipids: [TC, LDL, HDL, TG] — Date: [date]
• Anticoagulation/drug levels: [INR, anti-Xa, drug level if applicable] — Date: [date]
• Other pertinent data: [Relevant diagnostics, immunization status]
• Pending/unavailable: [Data element] ordered/requested from [source]; expected [timeframe]

Assessment: Medication Therapy Problems

(Provide a prioritized list. For each MTP, include actionable title, linked conditions/medications, brief supporting evidence, MTP domain, and alignment with patient goals. If no MTPs identified, document: "No medication therapy problems identified today. Current regimen assessed as appropriate, effective, safe, and patient able to take as intended based on available information.")

#[1] ([High / Moderate / Low] Priority – [Indication / Effectiveness / Safety / Adherence]): [Actionable MTP title]

• Linked conditions/medications: [Condition(s)]; [Medication(s)]
• Evidence: [Symptoms, objective data, patient report, fill history]
• MTP Domain: [Indication / Effectiveness / Safety / Adherence]
• Goal alignment: [How resolving this advances patient's stated goals]

#[2] ([High / Moderate / Low] Priority – [Indication / Effectiveness / Safety / Adherence]): [Actionable MTP title]

(Add additional problems as needed.)

• Linked conditions/medications: [Condition(s)]; [Medication(s)]
• Evidence: [Brief supporting data]
• MTP Domain: [Indication / Effectiveness / Safety / Adherence]
• Goal alignment: [How this advances patient goals]

Plan

(Organize by problem corresponding to the Assessment. Use explicit language: "Recommendation to prescriber:" for suggestions requiring approval; "Ordered/prescribed under CPA:" for executed changes; "Patient instructed:" for self-management guidance.)

Problem #[1]: [Actionable MTP title]

• Therapeutic Goal: [Specific, measurable target with timeframe]
• Medication Plan:
  • Recommendation to prescriber: [start/stop/change; drug, dose, route, schedule; rationale]
  • Ordered/prescribed under CPA: [action executed today with details]
  • Patient instructed: [self-management guidance; titration instructions; missed-dose instructions]
• Non-pharmacologic Plan: [Lifestyle modifications, device technique education, adherence tools initiated]
• Monitoring: [What to monitor]; [when/timeframe]; [responsible party]; [action thresholds]
• Implementation Status: [Completed today vs pending tasks]
• Communication: [Who notified, method, summary of information transmitted]

Problem #[2]: [Actionable MTP title]

• Therapeutic Goal: [Target]
• Medication Plan: [Details]
• Non-pharmacologic Plan: [Details]
• Monitoring: [Details]
• Implementation Status: [Details]
• Communication: [Details]

Patient Education and Shared Decision-Making

• [Medication counseling provided: indications, key side effects, administration technique, missed-dose instructions]
• [Risk-benefit discussion for high-risk changes; patient preferences considered]
• [Teach-back used: yes/no]; Patient demonstrated understanding of: [topics]
• [Materials provided: written plan, medication list, device instructions, adherence supports]

Care Coordination

• [Date] — [Recipient/role] via [EHR message / phone / fax]: [Summary of communication]
• Referrals placed: [Service, reason, status]
• Prior authorization/coverage: [Medication, payer, status/next steps]
• Transitions-of-care coordination: [Discharge reconciliation, outreach, handoffs if applicable]

Follow-up Plan

• Next visit: [Timeframe] via [in-person / video / phone]
• Reassess: [Specific MTPs, labs, vitals, symptoms, adherence to evaluate]
• Interim monitoring: [Phone call, refill monitoring, device data review] by [responsible party] around [date]
• Red-flag symptoms/escalation: [What to watch for; whom/how to contact; emergency instructions]

(If no follow-up scheduled, document reason and monitoring handoff plan.)