MTM Comprehensive Medication Review Note (Medicare Part D)

Date of Service: [Date] | Start Time: [HH:MM] | End Time: [HH:MM]

Encounter Mode: [in-person / synchronous telehealth - telephone / synchronous telehealth - video]

Location: [clinic / pharmacy / patient home / LTC facility / telehealth location]

Beneficiary: [Name] | DOB: [MM/DD/YYYY] | Phone: [Number] | Address: [Street, City, State ZIP]

Medicare Part D Plan: [Plan name] (If not available, state "Plan ID not available to MTM provider.")

MTM Provider: [Name], [Credentials] | [Organization]

Participants: [Beneficiary / Authorized representative / Caregiver] (If not the beneficiary, document relationship/authority and reason beneficiary did not participate. Note if interpreter used and language.)

MTM Program Context

[Enrollment status], [Date of last CMR if known], [annual / initial] CMR. Reason for review: [annual requirement / transition of care / recent hospitalization / adherence concern / patient request / prescriber request / other]. (If eligibility details are not visible to the MTM provider, state that eligibility was determined by plan targeting.)

Patient Goals and Concerns

[Beneficiary-stated priorities and goals for medication therapy]. [Medication-related concerns including symptoms or adverse effects]. [Adherence barriers if identified: cost, regimen complexity, side effects, cognition, dexterity, access]. [Recent care changes: hospitalizations, new diagnoses, new prescribers]. [Relevant social factors affecting medication use]. (If plan-initiated without specific complaints, document that and note priorities identified during the consultation.)

Medication and Allergy Reconciliation

Sources Reviewed: [beneficiary interview / medication bottles / pharmacy dispensing records / EHR / caregiver report / facility MAR]

Current Medication List:

Medication	Strength/Form	Directions	Indication	Prescriber	Notes
[Medication name]	[Strength/Form]	[Directions]	[Indication]	[Prescriber]	[Adherence, technique, cost/formulary, high-risk flags]

(Include all prescription medications, OTC products, vitamins/minerals, and supplements. Add rows as needed. If the medication list cannot be fully reconciled, document which items are confirmed versus pending verification.)

Allergies and Adverse Reactions: [Drug allergies with reaction type and severity if known; relevant non-drug allergies] (Document "No known drug allergies (NKDA)" only if confirmed; otherwise state "Allergy status not confirmed.")

Clinical Information

(Include only if data is available and relevant to medication decisions; otherwise omit this section entirely.)

• Active Conditions: [Diagnoses relevant to medication regimen]
• Objective Measures: [BP, weight, A1c, renal function, INR, relevant labs]
• Recent Healthcare Utilization: [Hospitalizations or ED visits relevant to medication management]

Medication Therapy Problems

(List in priority order: safety issues first, then disease control, then adherence/optimization. Clearly label any inferences with supporting evidence.)

1. Problem: [Clear, nonjudgmental description]

   Clinical Significance: [Why this matters; potential risk or outcome impact]

   Supporting Evidence: [Patient report / refill patterns / labs / clinical notes]

   Urgency: [Recommended timeframe for resolution]

(Add additional MTPs as needed. If no MTPs identified after comprehensive review, document: "No medication therapy problems identified based on available information.")

Interventions and Recommendations

(Organize by MTP number. Clearly distinguish recommendations from confirmed changes.)

• MTP #[number]:

  • Action: [start / stop / change / dose adjustment / therapeutic interchange / adherence intervention / monitoring / referral]
  • Rationale: [Brief clinical reasoning]
  • Owner: [beneficiary / prescriber / pharmacy]
  • Patient Agreement: [agreed / declined / undecided] (If declined or undecided, note reason.)
  • Monitoring: [Parameters and timeframe]
  • Status: [Recommendation provided - pending / Verified implemented on date]

Prescriber Outreach

(If no outreach required, state "No prescriber outreach required based on findings" and omit remainder of section.)

• Recipient: [Name, role, office] | Date/Time: [MM/DD/YYYY HH:MM] | Method: [phone / fax / EHR message]

  Summary: [Recommendations or questions posed]

  Outcome: [accepted / declined / pending / unable to reach] (If pending, note planned follow-up.)

Deliverables and Patient Education

CMS Standardized Format Deliverables:

• Cover Letter: [completed / not completed]
• Personal Medication List (PML): [completed / not completed]
• Medication Action Plan (MAP): [completed / not completed / completed with no action steps identified]

Delivery: Provided to [beneficiary / authorized representative] via [mail / electronic / handout] on [date]. (If electronic, confirm consent on file.)

Safe Disposal Information: [Provided this encounter / Previously provided on date / Not applicable - no controlled substances]. (If provided, note content: take-back locations, in-home disposal options.)

Patient Education: [Topics covered: medication purpose, administration technique, side effects and warning signs, self-monitoring, keeping PML updated for appointments, other tailored education]

Disposition and Follow-Up

CMR Status: [Completed / Partially completed / Declined] (If declined or partial, document reason and any alternative interventions provided.)

Follow-Up Plan: [Next planned contact or trigger for follow-up]. [Open action items with owner and target date].

Attestation and Signature

A real-time interactive consultation was conducted in the mode documented above. The medication list, including prescription and over-the-counter medications and supplements to the extent available, was reviewed and reconciled. The CMS Standardized Format written summary (PML and MAP) [was provided / will be provided within required timeframes].

Signature: [Provider name, credentials] | [Date/Time signed]