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Date:_____________  Student: _______________________________________________________

Evaluator: ______________________________

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SS2Clinician-Directed History-Building Skills and

SS3 Educate, Counsel and Plan

Dialogue Content

Not Done (ND) or Needs Improvement

Meets

Verifies correct patient name with name on Rx label

□ ND/used only first or last name

□ Used both first and last name

Asks for a second identifier to establish correct patient (eg, DOB; address; phone number)

□ Not done

□ Done

Asks: “What did your prescriber tell you the medication is for?”

□ Not done

□ Asked a closed-ended question

□ Asked an open-ended question

Provides drug names: states brand and generic drug names

Generic: Hydrochlorothiazide or HCTZ (either acceptable);

Brand (multiple available; write student answer here): ________________

□ ND/mispronunciation/both names not stated

Both drug names stated clearly

Shows patient drugs: Opens bottle and shows patient bottle contents

□ ND/contents not seen

□ Contents easily seen

Asks: “How did your prescriber tell you to take the medication?”

□ Not done

□ Asked a closed-ended question

□ Asked an open-ended question

Provides dose (eg, 10 mg; 10 is the number, mg is the units)

25 mg

□ ND/number and units missing

□ Done

Provides route

By mouth

□ Not done

□ Done

Provides schedule along with # of tablets to reinforce schedule

Once daily (1 tablet daily)

□ ND/schedule lacks clarity

□ Done

Provides missed dose instructions

Take the missed dose as soon as you remember; do not double up on doses to make up for missed dose

□ Not done

□ Done

Provides storage conditions information

Store at room temperature, away from light, heat, and moisture

□ ND/info irrelevant or ineffective

□ Info is relevant to safe and effective drug use

Asks: “What did your prescriber tell you to expect?”

□ Not done

□ Asked a closed-ended question

□ Asked an open-ended question

Explains benefits to be expected

Will lower your blood pressure; you may not feel any different

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains onset of action (time) This drug will increase your urination within about 2 hours; it may take about 3–4 days for you to see a change in your blood pressure

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains duration of therapy/drug action

This drug is a diuretic; it blocks reabsorption of sodium and chloride in your kidneys; reduces blood pressure

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Presents common side effects

Dizziness, especially upon standing and upon first starting this medication (should resolve over time); increase in urination (expected as this is how the medication works—consult prescriber or pharmacist if this is interfering with your work)

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Presents possible severe reaction

A severe rash/Stevens-Johnson syndrome; can cause electrolyte imbalances that may lead to an irregular heart rhythm

□ ND/info irrelevant or ...

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