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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

Generic: Hydrochlorothiazide or HCTZ (either acceptable) with lisinopril;

Brand: Prinzide, Zestoretic (either acceptable)

Other (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)

10 mg of lisinopril and 12.5 mg of HCTZ

□ 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 combination of two medications; one is a diuretic; it blocks reabsorption of sodium and chloride in your kidneys; reduces blood pressure. The other is an ACE inhibitor, which prevents your body from forming hormones that increase your blood pressure, so the medication helps to lower your blood pressure two ways.

□ 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 ...

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