) interface with the patient care process to create an MTM Service Model.
Source: American Pharmacists Association Core elements Version 2.0. Available at: www.pharmacist.com/mtm/CoreElements2. Accessed May 10, 2012.
APPENDIX 11.B
Sample Personal Medication Record
Patients, professionals, payers, and health information technology system vendors are encouraged to develop a format that meets individual needs, collecting elements such as those in the sample personal medication record (PMR) on the next page.
(Note: Sample PMR is two pages or one page front and back)
Note: This form is based on forms developed by the American Pharmacists Association and the National Association of Chain Drug Stores (NACDS) Foundation. Reproduced with permission from APhA and NACDS Foundation.
Source: American Pharmacists Association Core elements Version 2.0. Available at: www.pharmacist.com/mtm/CoreElements2. Accessed May 10, 2012.
APPENDIX 11.C
Sample Medication-Related Action Plan (for the Patient)
Patients, professionals, payers, and health information technology system vendors are encouraged to develop a format that meets individual needs, collecting elements such as those in the sample personal medication-related action plan (MAP) on the next page.
Note: This form is based on forms developed by the American Pharmacists Association and the National Association of Chain Drug Stores Foundation. Reproduced with permission from APhA and NACDS Foundation.
Source: American Pharmacists Association Core elements Version 2.0. Available at: www.pharmacist.com/mtm/CoreElements2. Accessed May 10, 2012.
APPENDIX 11.D
Example Prescription Profile
SN is a 56-year-old Asian female who presents to the pharmacy in January for a refill on her hydrochlorothiazide 25 mg. Her prescription profile is as follows:
| Refill Dates | Medication | Quantity |
| 12/1/10, 8/6/10, 7/5/10, 3/23/10, 1/22/10 | Hydrochlorothiazide 25 mg | 30 |
| 12/1/10, 8/6/10, 7/5/10, 3/23/10, 1/22/10 | Lisinopril 5 mg | 30 |
| 12/1/10 | Albuterol inhaler | 1 |
| 12/1/10 | Azithromycin 500 mg | 6 |
| 12/1/10, 11/1/10, 10/2/10, 9/2/10, 8/1/10, 7/1/10 | Atorvastatin 10 mg | 30 |
