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MED-PASS:  Designing Solutions for Senior Care

Medication Profile and Potential Side Effects Form - 100/pack


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Price: $28.60
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Co-Developed with American Society of Consultant Pharmacists


This popular addendum to the Comprehensive Assessment provides at-a-glance information that includes:

  • Listing of the home care patient’s medication regimen for up to 23 medications with space to document who is administering each medication.
  • Up to four drug regimen reviews
  • Comprehensive side effects reference that now includes coding to identify High Alert Medications.
    • Administered via any route
    • Administered intravenously (IV)/injected subcutaneously/intramuscularly

The side effects reference acts as a teaching tool to help patients and their care givers identify and monitor for potential side effects associated with medications on the patient’s regimen.

    • Include side effects reference over 165 medication classes plus the addition of listings to document Over-the-Counter Medications (OTC) and Alternative/Complementary Medications or Dietary Supplements (ALT).

      Part One (white - Clinical Record) The face of this form contains the Medication Profile with space to document up to four Drug Regimen Reviews.

      Part Two (yellow - In-home Record) Provides a carbonless copy of Part One for in-home record The back of Part Two is the first page of a seven page Drug Class/Potential Medication Side Effects Reference that lists 165 medication classes, potential side effects associated with the medication class and provides lines for listing medications in that class being used by the patient.

      Parts Three, Four and Five (In-home Record) Parts Three, Four and Five contain the balance of the seven page expanded Drug Class/Potential Medication Side Effects Reference which contains a total of 165 medication classes.

      • Tall-Man lettering helps distinguish between "look-a-like" medication names.
      Size 8-1/2 x 11-1/4
      Unit Package of 100
      Number of Pages 9
      Other Info Handwritten
      Number of carbonless parts 5
      Hole Punch 5 holes left, 5 holes top