Medication Assessment Form

* = Required Information

Person Receiving Services (Name) *

Medication Self-Management

Number of different medications taken/day *

Number of dosage times/day *

Cognitive Status

Functional Limitations

History of Noncompliance

Is the home environment sanitary

Yes

If No, describe

Client knowledgeable regarding the medication regimen?

Yes

If No, describe education/resources provided and on-going needs

Medication reminders

Central storage of medication

Progress as Tolerated to self punching of medications

Provide education on medication name, indications for use and side effects

Observe swallowing of medication

What assistance with Medication Self- Management is required based on assessment? (✔) all that apply

Medication Set Up

Medication Administration

Coordination of Medications

Education with the Person Receiving Services

Housekeeping/Cleaning Support

Diversion of Medications

Is there “street value” of medications being used by individual?

Yes

If Yes, describe

Is the individual’s residence in a high risk location?

Yes

If Yes, describe

Number of residents or visitors to the home with access to medications

Other risk factors/protection of medications

Potential for diversion of medication

Low

Medium

High

Plan to address the risk (✔) all that apply

Continue to Monitor

Secure Medications (describe)

Other (describe)

Describe

Individual’s Visits Away from Home

How often does the individual leave the home?

How long is the individual gone and over what periods of time?

Are the trips generally

Planned

Unplanned

Is a medication management plan needed when the individual is away from home?

Yes

If Yes, describe

Medication Reconciliation

Is there a purpose identified for each medication?

Yes

Plan to Address

Is the drug therapy effective?

Yes

Plan to Address

Are the immediate desired effects of the medications evident?

Yes

Plan to Address

Are side effects present?

Yes

Plan to Address

Are any unusual or unexpected effects present?

Yes

Plan to Address

Were any actual or potential drug interactions identified?

Yes

Plan to Address

Is there duplicate drug therapy?

Yes

Plan to Address

Is any drug therapy currently associated with laboratory monitoring?

Yes

Plan to Address

Are any allergic reactions present?

Yes

Plan to Address

Are there changes in condition that contraindicate continued administration of the medications?

Yes

Plan to Address

Other (specify)

Coordination with other providers completed as a result of the medication reconciliation (✔) all that apply

Primary Care Provider

Pharmacy

Interdisciplinary Team (Guardian, Case Manager, Other Service Provider)

Other (specify)

Question / Comment

RN Full Name

Date