Headings
Current medication list · Adherence · Side effects · Interactions · Changes made · Patient education · Plan
When to use it
Use this when the visit is dedicated to the medication list itself, often for patients on many drugs or after several specialists have added prescriptions. It records adherence, side effects and interactions, then documents each change and what the patient was told. It suits deprescribing work that would get lost inside a general follow-up note.
Example
Fictional example
Current medication list
G.W., 79. Metoprolol 50 mg twice daily, omeprazole 40 mg daily for 6 years, simvastatin 40 mg, amlodipine 5 mg, diphenhydramine 25 mg nightly, aspirin 81 mg.
Adherence
Uses a weekly pill box filled by her son. Rarely misses doses.
Side effects
Morning grogginess. Dry mouth.
Interactions
Amlodipine raises simvastatin levels, dose above advised limit. Diphenhydramine is anticholinergic, a fall risk at her age.
Changes made
Simvastatin changed to atorvastatin 20 mg. Diphenhydramine stopped. Omeprazole reduced to 20 mg.
Patient education
Sleep hygiene reviewed. Son given updated written list.
Plan
Phone check in 2 weeks for sleep and reflux. Stop omeprazole in 1 month if reflux stays quiet.