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                          0—Did not complete

Student Name: ____________________________________  1—Partially not complete

Medication: ______________________________________   2—Fully completed

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Evaluation Elements Observer Rating

Verification/Past History (COLLECT):

Introduced self to the patient appropriately

0

1

2

Explained the purpose of the counseling session

0

1

 

Confirmed patient’s name and DOB with identifiers (address, phone number)

0

1

2

Verified prescriber’s name

0

1

2

Asked about medication allergies (with date and reaction)

0

1

2

Asked about other medications including prescriptions, OTCs, vitamins/supplements, samples

0

1

2

 • Used open-ended questions throughout this section

0

1

 

 • Maintained balanced eye contact

0

1

 

 • Used language understandable to the patient

0

1

 

 • Appeared confident and poised with appropriate speech volume, voice inflection, and pace

0

1

 

Three Prime Questions Discussed (ASSESS AND PLAN):

Intended use of medication (“What did your doctor tell you this medication is for?”)

0

1

2

How to take medication (“How did your doctor tell you to take the medication?”)

0

1

2

Expected positive benefits (and negatives) of medication use (“What did your doctor tell you to expect from this medication?”)

0

1

2

 • Used open-ended questions throughout this section

0

1

 

 • Maintained balanced eye contact

0

1

 

 • Used language understandable to the patient

0

1

 

 • Appeared confident and poised with appropriate speech volume, voice inflection, and pace

0

1

 

Prescription Information Discussed (IMPLEMENT):

Name of medication (including brand and generic)

0

1

2

Strength and dosage form

0

1

2

Showed medication to patient

0

1

2

Discussed appropriate administration steps for this specific medication device/dosage form

0

1

2

Precautions (eg, avoid alcohol, sun sensitivity) and special instructions (take with food)

0

1

2

Adverse effects (2–3 most common and 1 rare but severe)

0

1

2

Missed doses

0

1

2

Storage

0

1

2

Refills

0

1

2

 • Used open-ended questions throughout this section

0

1

 

 • Maintained balanced eye contact

0

1

 

 • Used language understandable to the patient

0

1

 

 • Appeared confident and poised with appropriate speech volume, voice inflection, and pace

0

1

 

Questions/Ending Counseling Session (FOLLOW-UP/MONITORING):

Asked patient if he or she has questions (“What questions do you have?”)

0

1

2

Effectively answered patient questions (Health Equity question)

0

1

2

Verified patient’s understanding of instructions on how to appropriately use the medication (Final Verification/Teach-Back) OR P2 year—appropriately addressed difficult patient

0

1

2

Provided information on what to do if patient has problems or questions

0

1

2

 • Used open-ended questions throughout this section

0

1

 

 • Maintained balanced eye contact

0

1

 

 • Used language understandable to the patient

0

1

 

 • Appeared confident and poised with appropriate speech volume, voice inflection, and pace

0

1

 

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