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PRECEPTOR CHECKLIST/ SIGN-OFF PHRM 771 Community IPPE
Student Name
_________________________________________________________________
Supervising Preceptor Name(s)
___________________________________________________
Location
______________________________________________________________________
INSTRUCTIONS
The following table outlines the primary learning goals and
activities for the Community IPPE. Each student should successfully
complete all items on the checklist by the end of the community
IPPE. The student should maintain the checklist and the preceptor
should review the checklist at the beginning of the rotation and
regularly thereafter (at least weekly). When a student successfully
completes an item on the checklist, the preceptor should initial
and date the item.
DO NOT wait until the last week of the rotation to begin having
items checked off. 1. Activities beyond discussion and observation
must be documented by the student. For those
activities that do not have a designated form, the student
should record the assignment results using a word-processing
program.
2. All documentation of assignment completion must accompany the
completed check list to earn full credit for the rotation.
Student to submit a hard copy of completed checklist and the
supporting documentation to the Office of Experiential Education no
later than August 17th 2015 (or January 25th 2016 for winter
schedule).
Teera SujithamrakElaine Lucero
Smith's Pharmacy #496 3701 Constitution NE Albuquerque, NM
87110
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Community IPPE Checklist
Objective 1.1
Describe the scope of the practice and the functions, roles and
accountabilities of its personnel as they relate to pharmacy
services and practice management. (Competency 4.2)
Student Preceptor Date
Observe and discuss the following with the preceptor (ideally
during week #1): x Number, roles and accountabilities of (functions
performed and skills needed by) pharmacists,
technicians and other personnel x Reporting relationships within
the site and company x Services offered by the practice x Workload
(e.g. numbers of prescriptions filled per day, impact of third
party plans) and work processes
Objective 1.2 Relate the characteristics of the patient base and
population of the surrounding community to the provision of and
need for pharmacist-provided services. (Competency 6.2)
Student Preceptor Date
Discuss with the preceptor aspects of the patient-centered
pharmacist-patient relationship (ideally during week #1) x
Appropriate sharing of power and responsibility between the
pharmacist, patient and caregivers x Importance of open and honest
communication between pharmacist and patient x Influence of age,
cultural sensitivity, health literacy and respect for the patients
individuality, emotional
needs, values, and life issues in achieving an effective
pharmacist-patient relationship, both in gathering information and
in achieving patient adherence to prescribed therapy and/or
prevention and health promotion strategies
x Relationship of the community pharmacy approach to the
establishment of the pharmacist-patient relationship, continuity of
care, and health promotion and disease prevention
Observe and discuss with the preceptor community demographics
and the patient base at this site, including age range,
ethnicities, level of education, predominant occupations,
socio-economic status, and predominant disease states (ideally
during week #1 or #2)
Objective 2.1 Describe and apply legal regulations and workflow,
policies, and procedures used to ensure the provision of safe and
effective drug products. (Activities below may be completed at any
time during rotation) (Competency 7.1 & 4.1)
Student Preceptor Date
Review and discuss with the preceptor the legal requirements for
dispensing prescription medications, including those for controlled
substances
Review and discuss with the preceptor the legal and ethical
principles governing the maintenance and communication of patient
information/ medical records.
Outline the legally required components of NM Board of Pharmacy
regulations for patient counseling. Observe and describe how these
components are utilized at practice site. Discuss key points of
patient counseling.
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Community IPPE Checklist
Observe pharmacists and pharmacy technicians through their daily
activities then review and discuss with the preceptor the policies
and workflow processes used in the practice to x order and manage
inventory of medications x store medications x verify prescription
authenticity and accuracy x to maximize efficiencies and minimize
medication-related errors when dispensing prescriptions
Identify five (5) medications used in the practice that are NOT
stored at room temperature and five (5) medications given by a
non-oral route of administration. List the specific storage
requirements for the 5 medications not stored at room temperature
and describe why these are necessary. For 5 medications not taken
by mouth, identify the route of administration and reason(s) why
the medication is administered by a non-oral route as well as
proper patient counseling for those medications. Record results for
inclusion with this report.
Discuss with preceptor the policies and procedures (workflow,
checks and balances) used to ensure provision of appropriate, safe
and effective drug products to patients. Include in your discussion
how the responsibilities and liabilities differ for pharmacists and
technicians in the medication use system as well as the attitudes
or behaviors that can contribute to unsafe practices.
Objective 2.2 Participate in the appropriate acquisition,
storage and inventory management of prescription and
non-prescription medications. (Activities below may be completed at
any time during rotation) (Competency 4.1)
Student Preceptor Date
Participate in the process of ordering medications from a
wholesaler or other supplier. Where possible, this should include
completion of forms necessary to acquire controlled substances.
Participate in the process of checking in and storing products
delivered to the practice site. Fill out a DEA 222 form Follow
companys protocol to perform inventory on CII substances. Review
how to document discrepancies in controlled substances. Discuss
with preceptor how to handle employee theft of controlled
substances or any medication.
Objective 2.3 Process and dispense prescription medications in
accordance with legal regulations and policies and procedures of
the practice. (Activities below may be completed at any time during
rotation) (Competency 1.5)
Student Preceptor Date
Follow at least five(5) new and five(5) refill prescriptions
from intake through the steps necessary to appropriately dispense
that prescription. Where possible, these should include at least
one each of the following
controlled substance prescription compounded prescription
receive prescription phoned in by physicians office request for
clarifying information and/or prescription refill approval from a
physicians office
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Community IPPE Checklist
Perform calculations necessary to compound, dispense a
prescription, or deliver a medication dose for a minimum of five(5)
prescriptions
Where available, demonstrate appropriate compounding technique.
We recognize that some sites do not provide this service.
Check prescriptions filled by pharmacy technicians on at least
five(5) occasions
Objective 3.1 Conduct Patient Interviews (Activities below may
be completed at any time during rotation) (Competency 1.1)
Student Preceptor Date
Interview a minimum of two patients to obtain patient specific
information necessary for the appropriate dispensing and use of
medications. One interview should be with a patient filling a new
prescription and a second to assess compliance with and
effectiveness and safety of a current medication at the time of
refill.
Conduct appropriate patient and physical assessment to assess
need for or response to drug therapy (e.g. observation of patient
appearance / behavior, pulse, blood pressure) for a minimum of two
patients (may be the same patients for whom interview is
conducted).
Objective 3.2 Identify and Resolve Drug Related Problems
1 (Activities below may be completed at any time during
rotation) (Competency 3.3)
Student Preceptor Date
Discuss with the preceptor ways in which data are systematically
collected and analyzed to identify and address drug-related
problems
Discuss with the preceptor how automated alerts for drug
interactions or duplication of therapy are handled in the
practice.
With the preceptor, communicate with patients and/or review of
patient medication records to identify a minimum of five(5) actual
or potential drug- related problems
1 DRPs may include compliance issue (over or underuse); adverse
drug reaction (actual or potential); drug selection problem (no
drug for identified condition, drug with no identified condition,
inappropriate/ suboptimal drug selection); drug regimen problem
(inappropriate dose, dosage form or route of administration);
drug-drug, drug-disease, or drug-food interaction (actual or
potential).
Objective 3.3 Evaluate and respond to drug information inquiries
(Ideally completed during week #3 but must be completed by last day
of rotation). (Competency 5.1)
Student Preceptor Date
Clarify, research and respond to a minimum of 2 drug information
questions including the identification of appropriate references.
With preceptor guidance, identify two drug information questions;
one from a patient and one from a health care provider and x
outline an appropriate search strategy for each x identify
appropriate resources x evaluate literature resources x prepare and
submit a written response using the DI documentation form
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Community IPPE Checklist
Objective 4.1 Provide patient counseling for the use of
prescription medications and related drug delivery or
self-monitoring devices (Note: if you dont see a patient like this,
talk to your preceptor about a preceptor-led demonstration.
activities below may be completed at any time during rotation).
(Competency 1.5)
Student Preceptor Date
Provide prescription medication use counseling, consistent with
NM Board of Pharmacy. Requirements, for a minimum of 5 patients
Teach patients to use drug delivery or self-monitoring devices,
including (where possible) but not limited to x subcutaneous
injections (e.g. measuring, mixing, and injecting insulin products)
x metered-dose and dry powder inhalers x blood glucose meters x
peak flow meters
Objective 4.2 Consult with Patients Regarding Non-prescription
Product Selection and Use (Activities below may be completed at any
time during rotation) (Competency 1.5)
Student Preceptor Date
Walk the OTC drug aisles and review OTC products. Conduct triage
and provide self-care recommendations for a minimum of 4 patients.
Document your interactions using the Self-Care Documentation Form
and provide copies to your preceptor for review.
Objective 5.0 Document pharmacists activities, interactions and
interventions with patients. (Competency 3.3)
Student Preceptor Date
Use inventory / information management tools to document the
acquisition and distribution of prescription and non-prescription
medications and devices at least once.
Use prescription processing / dispensing software system to
maintain accurate of patient information and dispensing records for
a minimum of five (5) patient encounters.
Adjudicate third-party payment claims for a minimum of five (5)
prescriptions or patient care services. Identify and document a
minimum of five actual or potential drug-related problems
identified through review of patient medication records and any
corrective actions taken.
Observe patient-pharmacist self-care (OTC) communications,
interventions and recommendations for a minimum of one (1)
patient.
Observe patient-pharmacist MTM communications, interventions and
recommendations for a minimum of one (1) patient.
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Community IPPE Checklist
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Objective 6.0 Promote public health and disease prevention
(activities below may be completed at any time during rotation)
(Competency 2.3)
Student Preceptor Date
Assigned Reading Read Using Health Observances to Promote
Wellness in Community Pharmacies (J Am Pharm Assoc. 2003, 43:61-68)
at http://japha.org/article.aspx?articleid=1035903 Discuss with
preceptor opportunities to promote patients health through
education and screenings as well as obstacles that may be
encountered. Discuss with preceptor your plans for a future event
(community outreach or education offering) that can be incorporated
into community pharmacy.
Discuss with the preceptor the current efforts of the practice
to promote population-based health maintenance and disease
prevention.
Identify and research at least five (5) community
resources/agencies in your community/area with which pharmacists
might interact. For each agency, provide contact information, a
brief summary of what they do and how they help patients.
Objective 7.0 Demonstrate mature and professional attitudes,
habits and behaviors (activities below may be completed at any time
during rotation) (Competency 7.3)
Student Preceptor Date
Assigned Reading Review the professionalism white paper
(Pharmacotherapy 2009;29(6):749756) Development of Student
Professionalism (HSLIC electronic journals) and print a copy for
your preceptor. Discuss with preceptor opportunities to promote
professionalism at your practice site as well as obstacles that may
be encountered.
Review the preceptor sign-off / checklist with preceptor on the
first day of the rotation and weekly thereafter. Make sure all
items are checked off by the last day of the rotation.
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Drug Information Documentation Form
State the question received: 1. Identify requestor
2. Why is the question being asked?
3. Formulate clear and specific drug information
question(s).
4. Classify drug information request by selecting all that
apply. Adverse effect Availability Compatibility/stability Cost
analysis Dose/dosage/administration Drug identification Drug
interaction
Drug compatibility/stability Drug therapy Patient Education
Pregnancy/lactation Pharmacy practice Pharmacology Other
_____________
5. Describe your strategy for conducting a systematic strategy
and cite references used. 6. Explain your process of resource
evaluation and analysis. Provide a concise substantiated
conclusion from the resources used. 7. Provide response to the
question.
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Drug Information Documentation Form
State the question received: 1. Identify requestor
2. Why is the question being asked?
3. Formulate clear and specific drug information
question(s).
4. Classify drug information request by selecting all that
apply. Adverse effect Availability Compatibility/stability Cost
analysis Dose/dosage/administration Drug identification Drug
interaction
Drug compatibility/stability Drug therapy Patient Education
Pregnancy/lactation Pharmacy practice Pharmacology Other
_____________
5. Describe your strategy for conducting a systematic strategy
and cite references used. 6. Explain your process of resource
evaluation and analysis. Provide a concise substantiated
conclusion from the resources used. 7. Provide response to the
question.
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Drug Information Instructions: These instructions are a guide to
completing the Drug Information Worksheet. Responses should be
concise with sufficient detail to show the thoroughness of the
search and appropriateness of the final response to the requestor.
Additional guidance can be found in Access Pharmacy Database Drug
Information: A Guide for Pharmacists The worksheet should not
exceed 2 pages in length. 1. Obtain information on the requestor.
The individual professional credentials (physician, pharmacist,
nurse, physician assistant, dentist, or lay person-
patient/caregiver) suggest educational experience and knowledge.
This can be used to determine the appropriate level to formulate
and deliver the response to the question(s).
2. Determine why the question is being asked. What information
is sought? Is it a specific patient or a
general question? Is the question prospective or retrospective?
Is the question for general information or to reach a clinical
decision? This information is helpful in formulating the
question(s) to be addressed.
3. The question must be carefully focused to address the
specific information needed to address the
particular situation. All pertinent/relevant factors must be
included patient, clinical situation etc.
Examples: Not Focused: What is the dose of amoxicillin? There is
not enough information here to answer a clinical question, or
address a specific patient needs.
Focused: What is the dose and frequency of amoxicillin before a
dental procedure for bacterial endocarditis prophylaxis in an 18
year old male? The question addresses a specific scenario and
allows the response to be focused.
4. Classifying the question allows for selection of the
appropriate resource. Selecting the right
reference focuses the search strategy and increases likelihood
of locating the correct response. See list of suggested references
for guidance.
5. List the resource(s) that you selected for the search based
on the probability of locating the requested
information. These should be prioritized based on your knowledge
of what information is most likely to be found in a particular
reference. Alternatively, you may have selected resources based on
ease of access or your comfort in use. If so, state such. Provide
your search strategy this can be done via cut and paste of the URL
or typed out [e.g. PubMed: pediatric + ear infection]
Describe how you conducted a systematic search. A logical
progression is to begin with the information located within the
tertiary literature and then move to secondary/primary to fine tune
information. If you use secondary literature to access the primary
literature, briefly list your search terms. The description should
include the confirming reference(s) used to format the
response.
When applicable, the use of non-standard references may be used
provided they are critically analyzed for credibility. Use of such
resources must be explained including the critical analysis. These
may include websites or non-referee journal publications.
Cite your references using AMA style as found at
http://www.docstyles.com/amaguide.htm . All references used in the
final answer should be listed. Include any confirming information
as well as the original article/reference.
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6. Evaluate and analyze the findings and confirm with other
references for appropriateness, accuracy
and reliability. Is the reference current and supported by other
references? In instances where conflicting information is found,
provide an evaluation and analysis of how you selected the best
reference to be used for this specific question.
7. Synthesize your findings in to a single comprehensive
conclusion. Response should show
thoughtfulness and applicability to the question asked. Response
should explain why one reference was selected over another when
appropriate.
Prepare a concise (less than 100 words) response to the
requestor. Begin the response by answering the question. Provide
more details as needed. Compose the response at the comprehension
level of the requestor. References should be incorporated into the
final response.
Helpful Hints for Answering Drug Information Questions It is
acceptable to begin with a tertiary resource for background data.
If you begin with a tertiary reference, review any cited primary
literature. The presented may not fully represent the entire
primary reference. Many questions will require a literature search
even if you find an answer in a tertiary reference. When doing a
literature search, be sure to review older data if available. Just
because the information is older does not mean that it is not
relevant or useful. x Any resource information should be double
checked against another reference to establish credibility.
A review of cited primary literature is often effective in
establishing a credible response. x When using clinical guidelines,
verify that the guidelines are supported by a professional
organization. x Confirm that the guidelines selected are the most
recent AND are those most appropriate for this
specific question. When guidelines conflict, perform an
evaluation to determine the best answer. x Both safety and efficacy
data are important when reviewing a drug therapy. If your
reference(s) do not address these, comment within your final
response. Consider adding common side effects/uses or populations
in whom the drug should not be used.
x Always answer the question in the first sentence of the
written response. x The final response should be complete such that
the person asking the question could treat a
patient immediately with the information you provide. Dosage
information and/or a brief summary of the efficacy/safety data
should be provided.
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Self-Care Documentation Form
9
Patient Information: Initials: __________ Male Female Pregnant
Breastfeeding Patient Age: < 2 years 217 years 18-64 years t65
years Describe chief complaint:
Area of Chief Complaint: Allergy Cold Constipation Cough
Dermatology Diarrhea
Headache Heartburn Fever Ophthalmic Otic Tobacco cessation Other
__________________
Patient Assessment Suggested questions to focus chief complaint:
a. Symptoms: What are the main and associated symptoms? b.
Characteristics: What is the situation like? Is it changing? c.
History: What has been tried so far? Have you had this before? d.
Onset: When did it start? e. Location: Where is the problem
located? f. Aggravating Factors: What makes it worse? g. Remitting
Factors: What makes it better? h. Medications: Are you taking any
prescription or non prescription drugs? Herbal products,
vitamins
or dietary supplements? i. Allergies: Do you have any allergies
to food or medication? If so, what are they? j. Coexisting
conditions: Do you have any other medical conditions or health
problems? Patient Analysis 1. List the issues identified. 2.
Assessment of current medication therapy (if applicable) 3.
Assessment of current medical condition. 4. Treatment goals:
Patient is a self-care candidate Refer patient to _________________
due to _______________________________________.
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Possible Self-Care Strategies Possible General care measures:
Possible non-prescription medication: (list all options and
justifications) Recommendations to Patient General care measures
recommended: Non-prescription medications recommended. (Include
name, strength, route, frequency & duration) Patient education
(i.e., medication administration technique, adverse effects,
expectations, monitoring). Student Name:
____________________________________________ Date:
___________________
Reviewed by Pharmacist: _________________________________ Date:
___________________
Retain copy in work book.
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Self-Care Documentation Form
9
Patient Information: Initials: __________ Male Female Pregnant
Breastfeeding Patient Age: < 2 years 217 years 18-64 years t65
years Describe chief complaint:
Area of Chief Complaint: Allergy Cold Constipation Cough
Dermatology Diarrhea
Headache Heartburn Fever Ophthalmic Otic Tobacco cessation Other
__________________
Patient Assessment Suggested questions to focus chief complaint:
a. Symptoms: What are the main and associated symptoms? b.
Characteristics: What is the situation like? Is it changing? c.
History: What has been tried so far? Have you had this before? d.
Onset: When did it start? e. Location: Where is the problem
located? f. Aggravating Factors: What makes it worse? g. Remitting
Factors: What makes it better? h. Medications: Are you taking any
prescription or non prescription drugs? Herbal products,
vitamins
or dietary supplements? i. Allergies: Do you have any allergies
to food or medication? If so, what are they? j. Coexisting
conditions: Do you have any other medical conditions or health
problems? Patient Analysis 1. List the issues identified. 2.
Assessment of current medication therapy (if applicable) 3.
Assessment of current medical condition. 4. Treatment goals:
Patient is a self-care candidate Refer patient to _________________
due to _______________________________________.
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Possible Self-Care Strategies Possible General care measures:
Possible non-prescription medication: (list all options and
justifications) Recommendations to Patient General care measures
recommended: Non-prescription medications recommended. (Include
name, strength, route, frequency & duration) Patient education
(i.e., medication administration technique, adverse effects,
expectations, monitoring). Student Name:
____________________________________________ Date:
___________________
Reviewed by Pharmacist: _________________________________ Date:
___________________
Retain copy in work book.
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Self-Care Documentation Form
9
Patient Information: Initials: __________ Male Female Pregnant
Breastfeeding Patient Age: < 2 years 217 years 18-64 years t65
years Describe chief complaint:
Area of Chief Complaint: Allergy Cold Constipation Cough
Dermatology Diarrhea
Headache Heartburn Fever Ophthalmic Otic Tobacco cessation Other
__________________
Patient Assessment Suggested questions to focus chief complaint:
a. Symptoms: What are the main and associated symptoms? b.
Characteristics: What is the situation like? Is it changing? c.
History: What has been tried so far? Have you had this before? d.
Onset: When did it start? e. Location: Where is the problem
located? f. Aggravating Factors: What makes it worse? g. Remitting
Factors: What makes it better? h. Medications: Are you taking any
prescription or non prescription drugs? Herbal products,
vitamins
or dietary supplements? i. Allergies: Do you have any allergies
to food or medication? If so, what are they? j. Coexisting
conditions: Do you have any other medical conditions or health
problems? Patient Analysis 1. List the issues identified. 2.
Assessment of current medication therapy (if applicable) 3.
Assessment of current medical condition. 4. Treatment goals:
Patient is a self-care candidate Refer patient to _________________
due to _______________________________________.
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10
Possible Self-Care Strategies Possible General care measures:
Possible non-prescription medication: (list all options and
justifications) Recommendations to Patient General care measures
recommended: Non-prescription medications recommended. (Include
name, strength, route, frequency & duration) Patient education
(i.e., medication administration technique, adverse effects,
expectations, monitoring). Student Name:
____________________________________________ Date:
___________________
Reviewed by Pharmacist: _________________________________ Date:
___________________
Retain copy in work book.
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Self-Care Documentation Form
9
Patient Information: Initials: __________ Male Female Pregnant
Breastfeeding Patient Age: < 2 years 217 years 18-64 years t65
years Describe chief complaint:
Area of Chief Complaint: Allergy Cold Constipation Cough
Dermatology Diarrhea
Headache Heartburn Fever Ophthalmic Otic Tobacco cessation Other
__________________
Patient Assessment Suggested questions to focus chief complaint:
a. Symptoms: What are the main and associated symptoms? b.
Characteristics: What is the situation like? Is it changing? c.
History: What has been tried so far? Have you had this before? d.
Onset: When did it start? e. Location: Where is the problem
located? f. Aggravating Factors: What makes it worse? g. Remitting
Factors: What makes it better? h. Medications: Are you taking any
prescription or non prescription drugs? Herbal products,
vitamins
or dietary supplements? i. Allergies: Do you have any allergies
to food or medication? If so, what are they? j. Coexisting
conditions: Do you have any other medical conditions or health
problems? Patient Analysis 1. List the issues identified. 2.
Assessment of current medication therapy (if applicable) 3.
Assessment of current medical condition. 4. Treatment goals:
Patient is a self-care candidate Refer patient to _________________
due to _______________________________________.
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10
Possible Self-Care Strategies Possible General care measures:
Possible non-prescription medication: (list all options and
justifications) Recommendations to Patient General care measures
recommended: Non-prescription medications recommended. (Include
name, strength, route, frequency & duration) Patient education
(i.e., medication administration technique, adverse effects,
expectations, monitoring). Student Name:
____________________________________________ Date:
___________________
Reviewed by Pharmacist: _________________________________ Date:
___________________
Retain copy in work book.