Nms Patient Record Form – Fill Out and Use This PDF

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

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Patient has withdrawn consent for information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Patient has withdrawn consent to receive the NMS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)

New medicine:

Date

Date

I) Maters identified during the discussion

Initial

Follow-up

intervention

Patient reports……

a) Action taken / to be taken by pharmacist

Initial

Follow- up

intervention

Information provided:

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