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Date:_____________ Student: _______________________________________________________

Evaluator: ______________________________

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SS2 : Clinician-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

□ 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)

□ ND/number and units missing

□ Done

Provides route

□ Not done

□ Done

Provides schedule along with # of tablets to reinforce schedule

□ ND/schedule lacks clarity

□ Done

Provides missed dose instructions

□ Not done

□ Done

Provides storage conditions information

□ 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

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains onset of action (time)

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains duration of therapy/drug action

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Presents common side effects

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Presents possible severe reaction

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains drug interactions with food/drink/other drugs

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains contraindications with drug use

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Provides techniques for monitoring

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Provides steps to avoid/minimize adverse reactions and what to do if occur

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Explains when to seek medical attention

□ ND/info irrelevant or ineffective

□ Relevant to safe and effective drug use

Rate your confidence in the pharmacy student’s recommendation (circle one):

1 : No confidence, I would not follow their recommendation.

2 : Not very confident, I might follow their recommendation.

3 : Unsure whether or not I would follow their recommendation.

4 : Confident, I would more than likely follow ...

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