First Home Visit Form: Hypertension |
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
First Home Visit Form: Hypertension |
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE
MINORITY HEALTH (PCCC) INITIATIVE
Date:_____________________
Patient name (Last name, First initial): _________________________________
Client ID #: ____________________________
Pharmacist Conducting Home Visit: ________________________________
Home Visit Date: ______________________
Section I. Patient Demographics:
Pharmacist Step #1: Introduction and collect baseline information. |
On
eligibility form
On
eligibility form
Baseline
blood pressure screening: _________________
Wt:
________________ lbs
Ht:
_______ feet ________ inches
How
long have you had high blood pressure? _______________
What is your current household income per year?
$0 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000 or more
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average 40 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Section II: Hypertension Knowledge:
Pharmacist Step #2: Ask the patient the following questions and mark their answers. |
1. If someone’s blood pressure is 120/80, it is…
High
Low
Normal
Don’t know
2. If someone’s blood pressure is 160/100, it is…
High
Low
Normal
Don’t know
3. Once someone has high blood pressure, it usually lasts for …
A few years
5–10 years
The rest of their life
Don’t know
4. People with high blood pressure should take their medicine…
Everyday
At least a few times a week
Only when they feel sick
5. Losing weight usually makes blood pressure…
Go up
Go down
Stay the same
6. Eating less salt usually makes blood pressure…
Go up
Go down
Stay the same
7. High blood pressure can cause heart attacks.
Yes
No
Don’t know
8. High blood pressure can cause cancer.
Yes
No
Don’t know
9. High blood pressure can cause kidney problems.
Yes
No
Don’t know
10. High blood pressure can cause strokes.
Yes
No
Don’t know
Section III. PCCC Survey:
Pharmacist Step #3: Ask the patient the following questions and mark their answers.
The statements below describe attitudes and beliefs you may have about the health program you signed up for and your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box. |
1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5 = I strongly agree |
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1. I will learn new information to help me to manage my health condition |
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2. I will get useful information about my health condition |
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3. I expect to put what I learn from this program into practice |
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4. I expect to see positive changes in myself if I do what they teach me |
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5. I can do something to improve my health condition |
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6. It is very important to take care of your health |
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7. I am ready to improve my health |
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Section IV. Medication Use and Adherence
Pharmacist Step #4: Review the medications that the patient has OR has been prescribed. Create a medication chart with the patient. Fill out attached Appendix A Medication List with the patient. Questions to ask:
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11. Medication History:
Medication (Name/Strength) |
Purpose |
Schedule |
Date of Last Dose |
Special Instructions |
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15.
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16.
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HYPERTENSION |
Always |
Very Often |
Sometimes |
Rarely |
Never |
12. How often have you forgotten to take your medicine for blood pressure in the past week? |
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13. How often do you stop taking your medicine for high blood pressure because you were careless? |
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14. How often do you stop taking your blood pressure medicine because you feel better? |
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15. How often do you stop taking your medicine for blood pressure when you experience side effects? |
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16.
Please find the statement that best describes the way you feel right
now about taking your high blood pressure medication as directed.
No, I do not take and right now am not considering taking my high blood pressure medication as directed. (Precontemplation)
No, I do not take but right now am considering taking my high blood pressure medication as directed. (Contemplation)
No, I do not take but am planning to start taking my high blood pressure medication as directed. (Preparation)
Yes, right now I consistently take my high blood pressure medication as directed.
17. If the answer to question 16 is D, then ask: How long have you been taking your high blood pressure medication as directed?
≤3 months
>3 months to 6 months
>6 months to 12 months
>12 months
Section V. Pharmacist Step #5: Pharmacist Assessment:
If the answer to question 16 is D and the answer to question 17 is A or B, then the stage of change is
action. If the answer to question 16 is D and the answer to question 17 is C or D, then the stage of
change is maintenance.
Area/ Stage |
Precontemplation |
Contemplation |
Prepare |
Action |
Maintenance |
Adhere to medication |
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Blood pressure goal is: ____/___ Today blood pressure is/ is not (circle one) at goal.
Assessment Notes: _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Section VI. Pharmacist Step #6: Pharmacist Education Checklist:
Education Points
**Please make sure you have discussed the following items with the patient by initialing in the next column** |
Pharmacist’s Initials |
I have reviewed all of the patient’s medications with the patient.
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I have discussed all potential drug interactions with the patient.
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I have provided disease state education on blood pressure to the patient.
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I have discussed in detail the medications for blood pressure with the patient.
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I have discussed the importance of medication adherence with the patient.
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I have discussed over-the-counter medication use as it relates to blood pressure with the patient. |
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I have discussed how to read and understand prescription labels/packaging with the patient. |
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I have showed the patient how to use a pillbox for medication maintenance.
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I have discussed when to call in for refills with the patient.
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I have discussed blood pressure goals with the patient.
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Section VII. Pharmacist Step #7: Interventions/Recommendations made (check appropriate box per intervention and list each intervention):
Education on hypertension awareness
Diet: _______________________________________________________________________________
Exercise: _______________________________________________________________________________
Medication duplication: _______________________________________________________________________________
Condition not treated: _______________________________________________________________________________
Drug-disease interaction: _______________________________________________________________________________
Drug-food interaction: _______________________________________________________________________________
Drug-drug interaction: _______________________________________________________________________________
Inappropriate Dose: _______________________________________________________________________________
Therapeutic suggestion/alternatives: _______________________________________________________________________________
Noncompliant: _______________________________________________________________________________
Adverse drug event: _______________________________________________________________________________
Other: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Section VIII. Pharmacist Step #8: Follow up plan:
18. Remind the patient about the upcoming education session. Ask the patient when is a good time for your follow-up
telephone call after your education class next month?
Day: __________________ Date: ________________ Time: __________________
19. Patient will need more education in the following areas (by phone):
Medication management
Blood pressure self monitoring
Other: ___________________________________________________________
20. Does patient’s PCP need to be notified?
Yes
No
Why? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Department of Health and Human Services |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |