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Patient Interview and Counseling Template

Name: _____________
Directions: Each box is worth 1 point
__________

Student
Examiner:

Introduction:
Appropriately introduces self
Verifies patient identity

1. Subjective/Objective
CC: (Patient

says this when student pharmacist asks how she/he can help him)

HPI: (Note not all parts of SCHOLAR may apply to every case)
S
C:
H:
O:
L:
A:
R :
Additional question(s) student pharmacist may ask (MAX ____ points):

PMH:
Current Medications/Adherence:
Allergies/ADRs:
Social History: (As applicable: MAX ___ points)
Tobacco
ETOH/illicit drugs
Home life:
Occupation:
Exercise:
Dietary habits:

2. Physical Assessment Findings (if applicable):


Student pharmacist performs physical assessment, looks at what patient referring to, or asks to see
the condition
Student pharmacist reviews/interprets test results

3. Student pharmacist accurately identifies the patients chief complaint(s)

4. Student pharmacist develops a reasonable treatment plan that addresses the


patients condition
Interview counseling template/updated
Recommendation of appropriate OTC drug therapy [name of drug(s)]
8.3.14

Other recommendations (if applicable): Continue ____ because ____


____because ____
Recommendation of appropriate non-drug therapy:

Discontinue

Points will be deducted if the following drug or non-drug therapies are recommended (because inappropriate for
patient or not indicated):

______ (subtract 1 point)

______ (subtract 1 point)

5. Student pharmacist appropriately counsels patient by correctly using the 3 prime


questions and lay language:
What is the medication for?

This medication is for ____ [name of medication, indication, and explanation of how it works for
the chief complaint]

How should you take this medication?

Starting dose/frequency:

OTC max dose/frequency:


Length of self-care treatment:
Storage:

Administration guidelines (if applicable) (MAX ____ points)


For example: administration route, with or without food
Etc

What should you expect from this medication?

Onset:
Duration of effect:
Common ADEs and management:
Precautions (if applicable):
When to see or contact MD:

6. Closure/Final Verification

Student pharmacist asks patient to repeat back instructions (to check for patient
understanding)

Student pharmacist addresses any questions from the patient appropriately (if applicable)

Student pharmacist asks if there are any additional questions, clarifications and wraps up the
interview appropriately

Examiner comments/feedback:
1. What did the student do well? (e.g. organized interview, used lay language, audible,
appropriate pace, pronounced drug names appropriately, displayed caring attitude and empathy
with patient, listened to patient, made good eye contact, etc.)

2. What could be improved upon? Did the student ask for help from group members?

3.

Identify any significant treatment errors

TOTAL
SCORE:
________

Interview counseling template/updated


8.3.14

/__