Microsoft word - sample hmr.doc

Home Medicines Review & Management Plan Xxxxxx xxxxxxx Pharmacy

Dr xxxxxxxxxxxxxxxxxxx
Dear Dr xxxxxxxxxxxxxxxxxxx,

Thank you for your referral for Mrs. XXXXXXXXXXX XXXX (DOB 29/12/1931) who has a history of asthma,
COPD, diabetes mellitus Type 2, hypercholesterolaemia, hypertension & osteoarthritis.
I visited Mrs. XXXXXXXXXXX XXXX for a Home Medicines Review on Friday 15th July.
Allergies or adverse reactions: penicillin, tetanus, trimethoprim, vibramycin
During the interview Mrs. XXXXXXXXXXX XXXX explained that she was concerned that she often suffered from
headaches & is always tired. During the interview she explained she also has been experiencing bloody stools
which she thinks is due to hemorrhoids & is constipated. She also complained of bedsores.
Current Medications
Alendronate & cholecalciferol Salbutamol MDI
Paracetamol 500mg/codeine 30mg
Takes for headaches
Not currently using. Misplaced

Chest infection
Mega B complex
Nedocromil MDI
Not currently using
Bromhexine 0.8mg/ml
Donepezil 5mg

Any differences in this medicines list and your referral are in bold. Medicines in italics are included in her
Webster pack prepared by her pharmacy.
Actions already undertaken
Discussed non-medication techniques to relieve pain. The Medicines Review Company p: 1300780013 f: 1300780093 e: a: PO BOX 180, Drummoyne, NSW 1470 Home Medicines Review & Management Plan remembered to rinse her mouth after using her fluticasone inhaler. Discussed the benefits of staying mobile & active. Discussed dietary issues with regards to her fibre & calcium explained that she sometimes suffered from postural hypotension. Discussed the importance of keeping her visits up with her podiatrist & optometrist. Mrs. XXXXXXXXXXX XXXhas not seen an optometrist in a long time to check her eyes. Perhaps her pharmacist could recommend a local optometrist as part of monitoring for complications due to her diabetes. Mrs. XXXXXXXXXXX XXXXXX monitors Discussed targets & reviewed her glucometer technique. her blood glucose levels every morning. She told me that her average readings are about 4-6mmol/L but has noticed that it increases when she is ill. Discussed the importance of continual therapy. Perhaps her pharmacist could remind her to obtain a new handihaler. Findings and Recommendations
Findings & Recommendations
Management Plan
(to be completed by GP)
As you are privy, headache & weakness are common No action required
adverse effects of desvenlafaxine. These seem to be Mrs. Action (comment):
XXXXXXXXXXX XXXXXX’s main concerns & she feels may be due to her medication. Desvenlafaxine may also exacerbate hypertension. Consider the temporal relationship. As long as there is no other contraindications sertraline is well tolerated & have least potential for drug interactions mediated by the inhibition of CYP enzymes.1 Consider ceasing desvenlafaxine cross tapering whilst commencing sertraline at 25mg once daily.2 According to her dispense history Mrs. XXXXXXXXXXX No action required
XXXXXX has not been compliant with her inhalers. She has Action (comment):
been using her salbutamol inhaler more regularly & has been suffering from a phlegmy cough. Consider ceasing salbutamol nebuliser to avoid confusion & simplify regime. Consider recommending Mrs. XXXXXXXXXXX XXXXXX use a spacer. Regular use of salbutamol may increase the risk of adverse effects such as headaches which is an ongoing concern.3 Consider follow up discussions with Mrs. XXXXXXXXXXX XXXXXX to encourage her to commence nedocromil MDI as intended & using her fluticasone/salmeterol regularly in order to reduce the need for salbutamol. With regular use, if response is seen nedocromil dosage may be reduced to twice daily.4 And fluticasone/salmeterol can be reduced to The Medicines Review Company p: 1300780013 f: 1300780093 e: a: PO BOX 180, Drummoyne, NSW 1470 Home Medicines Review & Management Plan lowest effective dose. Consider reviewing her therapy & perhaps providing her & her daughters with a revised medication chart for her inhalers & an asthma management plan. Asthma management plan template available at As mentioned above Mrs. XXXXXXXXXXX XXXXXX has No action required
misplaced her Spiriva Handihaler. Consider follow up Action (comment):
discussions & encouraging compliance with tiotropium Mrs. XXXXXXXXXXX XXXXXX explained that she has not No action required
suffered for any GORD symptoms in a very long time. As you Action (comment):
are privy, long term PPI therapy may increase the risk of hip fracture, pneumonia & reduced vitamin B12 absorption.5 As you are privy constipation is also an adverse effect of esomeprazole. Consider gradually withdrawing esomeprazole over 4-6 weeks to avoid rebound symptoms after long term use. Consider introducing antacids to be used on a prn basis whilst weaning off esomeprazole.6 Mrs. XXXXXXXXXXX XXXXXX is constipated at the moment No action required
& is suffering from hemorrhoids. Consider recommending Action (comment):
Osmolax 2 scoops daily increasing to 2 to 3 times daily if required & commencing bulking agents daily. Recommend Proctosedyl ointment two to three times daily. Consider substituting metformin 500mg 1 twice daily for No action required
metformin XR 1000mg 1 daily to simplify medication regime. Action (comment):
As I was not privy to Mrs. XXXXXXXXXXX XXXXXX’s pathology results consider continuous monitoring of renal function as dosage may need to be adjusted accordingly. As I was not privy to Mrs. XXXXXXXXXXX XXXXXX’s No action required
pathology results consider monitoring vitamin B12. As Action (comment):
metformin & esomeprazole may interfere with vitamin B12 As I was not privy to Mrs. XXXXXXXXXXX XXXXXX No action required
vaccination schedule. Consider reviewing the next scheduled Action (comment):
influenza & pneumococcal vaccination. signature

Send completed plan to: The Medicines Review Company
1300780093 Email:
Post: PO BOX 180, Drummoyne, NSW 1470
The Medicines Review Company p: 1300780013 f: 1300780093 e: a: PO BOX 180, Drummoyne, NSW 1470 Home Medicines Review & Management Plan I understand that there may be sound clinical reasons why my recommendations may not be considered appropriate for Mrs. XXXXXXXXXXX XXXXXX. I would welcome advice on this and how these reports can be made more useful to you. I would be pleased to provide supporting literature or clarifications of any issue raised in the report. Once a Medication Management Plan is developed in consultation with the patient MBS item number 900 can be claimed. Yours sincerely, Tina Quach B.Pharm AACPA Accredited Consultant Pharmacist References 1. The Lancet, vol 373, issue 9677, p1759-1760, 23rd May 2009 [cited 17 July 2011] Available from; URL: 2. AMH 2011 online. Sertraline drug profile. 3. eMIMS [CD–rom]. Version 5.0. St Leonards, CMPmedica Australia Pty Ltd; 2011. Salbutamol drug profile 4. AMH 2011 online. Nedocromil drug profile 5.Shenfield G, Bampton P, Catto-Smith T, Crotty B, Desmond P, Ellard K et al. Therapeutic guidelines - gastrointestinal 2006 4th ed. Melboune, Therapeutic Guidelines Limited; 2006. p.52 6. NPS news 45: proton pump inhibitors: step-down to symptom control NPS 2009 [cited 8 Apr 2011] Available from; URL: This is a real example of a Home Medicines Review written
by one of our accredited pharmacists. The actual outcomes
in the medication management plan were as follows:
GP ceased Pristiq (dexvenlafaxine)
GP stated “Uses nebs only in severe chest infections. Pt
encouraged to use spacer. Has been given script for Seretide”
Patient given Spiriva Handihaler
GP ceased PRN Nexium
GP stated “has large rectal prolapse. Is having operation 5/8/11”
GP changed metformin to 500mg XR nocte (HbA1c 6.11%)
GP will monitor B12 at next visit.
GP stated vaccinations for influenza and pneumococcal both up to
Note: The purpose of this example is to illustrate the format and types of issues that may be identified during a HMR – obviously, the number and types findings/recommendations will vary between patients.
The Medicines Review Company p: 1300780013 f: 1300780093 e: a: PO BOX 180, Drummoyne, NSW 1470


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