Nms Patient Record Form PDF Details

The NMS Patient Record Form is a comprehensive document designed to systematically capture and record significant details and interactions related to a patient's journey through the New Medicine Service (NMS). Introduced in September 2011 by the Information Department, its primary function is to aid healthcare professionals, particularly pharmacists, in monitoring and supporting patients who are initiating new medications for the first time. The form meticulously outlines various sections starting from the basic entry information, including the date and method of entry to NMS, followed by detailed patient information such as name, date of birth, address, gender, ethnicity, and NHS number. It places a strong emphasis on the condition or therapy area of the new medicine, listing common conditions like Asthma/COPD, Type 2 Diabetes, Antiplatelet/Anticoagulant therapy, and Hypertension as examples. Progress records, including initial and follow-up interventions, are crucial elements that allow pharmacists to mark the progress made with each patient. Another significant part of the form is dedicated to healthy living advice provided at each intervention stage, covering areas like smoking, diet and nutrition, physical activity, alcohol consumption, sexual health, and weight management. The form also addresses reasons for a patient’s non-participation, captures the issues identified during patient-pharmacist discussions, and outlines actions taken by pharmacists or recommended to patients to enhance therapy effectiveness. This document is not just a formality; it's a tool to ensure better patient outcomes and adherence to prescribed treatments, while also allowing for a personalized healthcare approach. Contact details for the Information Department are provided, indicating the support available for users of the form.

QuestionAnswer
Form NameNms Patient Record Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnms forms, nms record form, nms form pdf, nms pdf

Form Preview Example

NMS – Patient Record Form

A) Date of entry to NMS:

Method of entry to NMS:

a)Referred by prescriber

b)Patient identified in the pharmacy

Please tick one

 

B)

Patient details

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

Gender:

Male / female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NHS Number:(where available)

 

 

 

 

 

 

 

 

 

 

 

C)

Registered GP practice:

 

 

 

GP name (optional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D)

Condition / therapy area(s) of new medicine

Select

E) Name(s) of new medicine(s) – please list

 

 

 

 

 

 

 

 

 

 

 

1)

Asthma / COPD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2) Diabetes (Type 2)

 

 

 

 

 

 

 

 

 

 

 

 

 

3) Antiplatelet / Anticoagulant therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4)

Hypertension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

September 2011. Produced by the Information Department. Contact the Information Department Direct dial: 01727 891 800 or 0844 7364 201 Email: information@npa.co.uk Online: www.npa.co.uk

NMS – Patient Record Form

F)

Progress record of NMS for this patient

Initial intervention

Follow up

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

Method

Please tick one

 

 

 

Face to face in the pharmacy

 

 

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G)

Healthy living advice

Engagement

Initial intervention

Follow-up

 

provided at each stage

(tick as appropriate)

(tick as appropriate)

(tick as appropriate)

 

 

 

 

 

 

 

a)

Smoking

 

 

 

 

 

 

 

 

 

 

b)

Diet and nutrition

 

 

 

 

 

 

 

 

 

 

c)

Physical activity

 

 

 

 

 

 

 

 

 

 

d)

Alcohol

 

 

 

 

 

 

 

 

 

 

e)

Sexual health

 

 

 

 

 

 

 

 

 

 

f)

Weight management

 

 

 

 

 

 

 

 

 

 

 

 

H)

Reason why patient did not participate in the

Initial intervention

Follow-up

 

stages:

 

 

 

 

 

 

 

a)

Prescriber stopped new medicine

 

 

 

 

 

 

b)

Patient has withdrawn consent for information

 

 

 

sharing

 

 

 

 

 

 

 

c)

Patient has withdrawn consent to receive the NMS

 

 

 

 

 

 

d)

Patient could not be contacted

 

 

 

 

 

 

 

e)

Other (Please specify)

 

 

 

 

 

 

 

 

 

September 2011. Produced by the Information Department. Contact the Information Department Direct dial: 01727 891 800 or 0844 7364 201 Email: information@npa.co.uk Online: www.npa.co.uk

NMS – Patient Record Form

The data below must be recorded for each new medicine that the patient has been prescribed

New medicine:

 

 

 

Date

Date

 

 

 

I) Maters identified during the discussion

Initial

Follow-up

 

intervention

 

 

 

 

Patient reports……

 

 

a)using the medicine as prescribed

b)not using the medicine as prescribed

i.has not started using the medicines

ii.is not using the medicine in line with the directions of the prescriber

iii.patient reports missing a dose in the last 7 days

c)need for more information about the medicine

d)experiencing side-effects

e)negative feeling – provide further details in text box below

f)uncertainty on whether medicine is working

g)concern about remembering to take the medicine

h)other – free text

j)Record data about outcome of the discussion with the patient

a) Action taken / to be taken by pharmacist

Initial

Follow- up

 

intervention

 

Information provided:

 

i.interactions with other medicines

ii.why am I using the medicine / what is it for

iii.how to use the medicine

iv.correct dose of the medicine

v.effects of the medicine on the body / how it works

vi.why should I take the medicine

vii.timing of the dose

viii.interpretation of side effect information

September 2011. Produced by the Information Department. Contact the Information Department Direct dial: 01727 891 800 or 0844 7364 201 Email: information@npa.co.uk Online: www.npa.co.uk

NMS – Patient Record Form

Advice provided:

 

Initial

Follow-up

 

 

 

 

intervention

 

 

 

 

 

ix.

reminder strategies to support use of medicine

 

 

 

 

 

 

x.

change to timing of doses to support adherence

 

 

 

 

 

 

xi.

how to manage or minimise side effects

 

 

 

 

 

 

xii.

Yellow card report submitted to MHRA

 

 

 

 

 

 

xiii.

reminder chart / MAR chart provided

 

 

 

 

 

 

xiv.

Referral: patient raised issues about new medicine to

Initial

Follow-up

 

be considered by prescriber - select reason(s) for

intervention

 

 

referral:

 

 

 

 

 

 

 

 

 

1)

drug interaction(s)

 

 

 

 

 

 

 

 

2)

potential side effect(s) / adverse drug reaction

 

 

 

 

preventing use of medicine

 

 

 

 

 

 

 

 

3)

patient reports not using the medicine any more

 

 

 

 

 

 

 

 

4)

patient reports never having started the

 

 

 

 

medicine

 

 

 

 

 

 

 

 

5)

patient reports difficulty using the medicine

 

 

 

 

 

 

 

 

 

 

a)

issue with device

 

 

 

 

 

 

 

 

 

 

b)

issue with formulation

 

 

 

 

 

 

 

 

6)

patient reports lack of efficacy

 

 

 

 

 

 

 

 

7)

patient reports problem with dosage regimen

 

 

 

 

 

 

 

 

8)

patient reports unresolved concern about the

 

 

 

 

use of the medicine

 

 

 

 

 

 

 

 

9)

other – free text

 

 

 

 

 

 

xv.

Other action for pharmacist – free text

 

 

 

 

 

b) Action for PATIENT to take

Initial

Follow-up

 

 

 

 

intervention

 

 

 

 

 

i.

Carry on using the medicine as prescribed

 

 

 

 

 

 

ii.

Use medicine as agreed during the initial intervention /

 

 

 

follow-up

 

 

 

 

 

 

 

iii.

Yellow card report submitted to MHRA

 

 

 

 

 

 

iv.

Other action – free text

 

 

 

 

 

 

 

 

September 2011. Produced by the Information Department. Contact the Information Department Direct dial: 01727 891 800 or 0844 7364 201 Email: information@npa.co.uk Online: www.npa.co.uk