Prioritized Problem List Related Drug Therapy Problem Issue Reason * Plan (If applicable) 1. 2. 3. 4. 5. 6. 7. * Reasons for altering drug treatment regimen Indication Effectiveness Needs Different Drug Unnecessary Needs Additional Dosage Too Low Product No medical additional More effective drug Wrong dose indication therapy available Condition refractory to Duplicate therapy Untreated condition frequency drug Treating avoidable Dosage form Drug interaction ADR inappropriate Not effective for Synergistic Drug inappropriate condition Safety Adherence Adverse Drug Reaction Dosage Too High Noncompliance Undesirable effect Wrong dose Directions not understood Unsafe drug for patient Wrong frequency Patient prefers not to take
Prioritized Problem List Problem Related Drug Therapy Issue (If applicable) Reason * Plan 1. 2. 3. 4. 5. 6. 7. * Reasons for altering drug treatment regimen Indication Effectiveness Unnecessary Needs Additional Needs Different Drug Product Dosage Too Low No medical indication additional therapy More effective drug available Wrong dose Duplicate therapy Untreated condition Condition refractory to drug frequency Treating avoidable ADR Dosage form inappropriate Drug interaction Synergistic Not effective for condition Drug inappropriate Safety Adherence Adverse Drug Reaction Dosage Too High Noncompliance Undesirable effect Wrong dose Directions not understood Unsafe drug for patient Wrong frequency Patient prefers not to take
S-265%2FU-14400-98880-81598%2F1458919696_MedicationReviewForm.2015.11.13.docx