APPENDIX 1

Guide to Medication Review and Reconciliation Pathway

Home Care Pharmacists meet patient / caregiver at patient's home / residential care
facility

Obtain the best-possible medication history

- Review background information.
- Conduct a patient/ carer interview.

Confirm the accuracy of the medication history

- Confirm using a second source (precription/ discharge note/ referral note etc.).
- Update the medication history if new information becomes available.

Reconcile the history with the precribed medicines

e.g. Reconcile the patient's own medications with discharge medication orders

Supply verified information for ongoing care

Supply all information about the patient's medicines to all involved in the patient's care

Dicharge Home Care Pharmacy Services / Subsequent sessions

Adapted from SHPA in focus Background Material - Medication reconciliation – November 2012

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 APPENDIX 10b
HCPS8b
CARTA PERUBATAN
Tarikh:___________________
KUANTITI & MASA AMBIL UBAT
LAIN-LAIN
Bil.
NAMA UBAT & KEKUATAN
(lekat ubat sebenar jika perlu)
KEGUNAAN
SEBELUM / SELEPAS
MAKAN
PAGI
☼
T/HARI PETANG
 ARAHAN
PENGGUNAAN
MALAM
( )am ( )pm ( )pm ( )pm

29
 APPENDIX 11
HCPS9
HOME CARE PHARMACY SERVICES REGISTRY
Pharmacy Department, Hospital/ Health Clinic: _________________________________________

Date
Rn /
No. Name Diagnosis Tel No. Address Notes
I.C No
Enrolment Discharge

32
 APPENDIX 12
HCPS10
HOME CARE PHARMACY SERVICES VISIT RECORD
Pharmacy Department, Hospital/ Health Clinic: _________________________________________
Year: _________

DATE OF SESSION (PLEASE STATE IF DISCHARGED)

NO. NAME RN / I.C No
JAN FEB MAC APR MAY JUNE JULY AUG SEPT OCT NOV DEC

33
 APPENDIX 13
Senarai Semak Kesan Sampingan Ubat-Ubatan Psikotropik

Ogos
Mac

Sep

Nov
Feb
Jan

Mei
Jun
Apr

Okt

Dis
Jul
Bil. Sila tandakan (√) jika jawapan ‘ya’

1. Pengetahuan ubat yang diambil

1.1 Adakah pesakit mengambil ubat seperti yang diarahkan?
1.2 Adakah pesakit tahu berapa jenis ubat yang perlu
diambil?
1.3 Adakah pesakit tahu berapa kali dia perlu ambil ubat
dalam satu hari?
1.4 Adakah pesakit tahu berapa biji ubat yang perlu diambil
pada setiap hari?
1.5 Adakah pesakit tahu nama ubat yang diambil?
2. Senarai semak kesan sampingan ubat
2.1 Kering mulut
2.2 *Meleleh air liur
2.3 *Pergerakan mulut / lidah tidak terkawal
2.4 *Ruam kulit
2.5 Kulit mudah peka pada cahaya matahari
2.6 *Badan menggeletar / menggigil
2.7 *Ketegangan Otot (Dystonia)
2.8 *Pergerakan kaki tidak terkawal (Tardive dyskinesia)

2.9 *Mata terbeliak / terbalik ke atas

2.10 *Ketegangan leher
2.11 *Berjalan seperti robot
2.12 Pening
2.13 *Rasa mengantuk
2.14 *Rasa gelisah dan tidak boleh duduk diam (Akathisia)

2.15 *Pergerakan yang perlahan (Bradykinesia)

2.16 *Perubahan fungsi seksual termasuk nafsu seks susah
mencapai kemuncak
2.17 *Kabur penglihatan
2.18 Sembelit
2.19 Susah buang air kecil
Ogos
Mac

Sep

Nov
Feb
Jan

Mei
Jun
Apr

Okt

Dis
Jul

Bil. Tindakan yang diambil (Sila tandakan (√) jika jawapan

‘ya’)

1.1 Tiada tindakan jika tiada kesan sampingan

1.2 Memerlukan penilaian yang lebih kerap
1.3 Kesan sampingan yang bertanda (*) memerlukan rujukan
kepada Pegawa Perubatan / FMS / Pakar Psikiatri untuk
tindakan selanjutnya

34
 APPENDIX 14

Assessment of Drug Side Effects (Antipsychotic Side Effect Checklist (ASC))

No. Problem Yes No Comment(s)
1. Loss of energy and drive:
Have you had trouble moving, getting going, or stating things? Do you feel slowed
down?
2. Feeling unmotivated or numb:
Have you had trouble getting motivated or wanting to do things you used to?
(Sometimes people describe this as “Feeling like a zombie”.
3. Daytime sedation or drowsiness:
Are you tired or sleepy during the day? Feelings of tiredness can happen throughout
the day or only at certain times.
4. Sleeping too much:
Do you sleep too much? Do you feel you sleep for too long? Do you have a problem
getting out of bed in the morning, or do you need to go back to sleep for a large part of
the day?
5. Muscle being too tense or stiff:
Do your muscles feel stiff or rigid? Do you feel cramps or muscle pains in the arms,
legs, or neck?
6. Muscles trembling or shaking:
Have you had any shaking or muscle trembling?
7. Feeling restless or jitter:
Have you had any feelings of restlessness? Do you ever feel like you want to “jump out
of your skin”?
8. Need to move around and pace; can’t stay still:
Do you often need to get up and pace around? Do you have trouble sitting still? Do you
still rock from one leg to the other?
9. Trouble getting to sleep or staying asleep (insomnia):
Do you have trouble falling asleep or getting to sleep when you want to? Do you wake
up during the night, or wake up too early in the morning?
10. Blurry vision:
Do you have blurry vision? Things may seem out of focus. People with blurred vision
may have trouble with reading printed words in newspapers.
11. Dry mouth:
Is your mouth too dry? Does it feel like you have cotton in your mouth? Does it seem
like your tongue sticks to the top of your mouth?
12. Drooling:
Do you have too much saliva (spit)? Is your pillow wet when you wake up?
13. Memory and concentration:
Do you have any memory problems? Are you more forgetful? Is it hard to concentrate?
Do you find it hard to follow conversations, watch programs on TV, or read?
14. Constipation:
Do you have problems with constipation?
15. Weight change:
Have you had any changes in weight? Do you feel that you are overweight? Do you
gain weight quickly, or cannot seem to go on diet? Are your clothes getting too big or
too small for you?
16. Changes in sexual functioning:
Do you have any sexual problems or difficulties? Sometimes people say they have
problems with low sex drive. Some men say they have difficulties with erections or
ejaculation, and some women say they have difficulty achieving orgasm.
17. Menstrual or breast problem:
If you have regular menstrual periods, have you had any menstrual problems lately?
Sometimes women stop having their normal periods, or have irregular periods. Have
you had this problem recently? Sometimes they maybe milk leakage from the breasts.

35
 APPENDIX 15

Toronto Side Effect Scale (TSES)

Within the last two weeks, have you experienced any of the following symptoms?
How much trouble did this side effect cause you?
(Physician: rate frequency and severity of the symptoms)
Frequency Severity
Never Some About Often Every No Extreme
times half day trouble trouble
the
time
1. Nervousness 1 2 3 4 5 1 2 3 4 5
2. Agitation 1 2 3 4 5 1 2 3 4 5
3. Tremor 1 2 3 4 5 1 2 3 4 5
4. Twitching/myoclonus 1 2 3 4 5 1 2 3 4 5
(muscle contraction)
5. Abdominal pain 1 2 3 4 5 1 2 3 4 5
6. Dyspepsia (stomach 1 2 3 4 5 1 2 3 4 5
upset)
7. Nausea 1 2 3 4 5 1 2 3 4 5
8. Diarrhoea 1 2 3 4 5 1 2 3 4 5
9. Constipation 1 2 3 4 5 1 2 3 4 5
10. Decreased appetite 1 2 3 4 5 1 2 3 4 5
11. Increased appetite 1 2 3 4 5 1 2 3 4 5
12. Weakness or fatigue 1 2 3 4 5 1 2 3 4 5
13. Dizziness 1 2 3 4 5 1 2 3 4 5
14. Postural 1 2 3 4 5 1 2 3 4 5
hypotension (dizzy
when getting up)
15. Drowsiness/daytime 1 2 3 4 5 1 2 3 4 5
somnolence
16. Increased sleep 1 2 3 4 5 1 2 3 4 5
17. Decreased sleep 1 2 3 4 5 1 2 3 4 5
18. Sweating 1 2 3 4 5 1 2 3 4 5
19. Flushing 1 2 3 4 5 1 2 3 4 5
20. Edema (fluid 1 2 3 4 5 1 2 3 4 5
retention)
21. Headache 1 2 3 4 5 1 2 3 4 5
22. Blurred vision 1 2 3 4 5 1 2 3 4 5
23. Dry mouth 1 2 3 4 5 1 2 3 4 5
24. Anorgasmia/no 1 2 3 4 5 1 2 3 4 5
orgasm
25. Increased libido 1 2 3 4 5 1 2 3 4 5
26. Decreased libido 1 2 3 4 5 1 2 3 4 5
(Men only: item 27 – 29)
27. Premature 1 2 3 4 5 1 2 3 4 5
ejaculation
28. Delayed ejaculation 1 2 3 4 5 1 2 3 4 5
29. Erectile dysfunction 1 2 3 4 5 1 2 3 4 5
30. Other, specify: 1 2 3 4 5 1 2 3 4 5

None ≤2 ≤4 lbs ≤6 ≤7 No Extreme

lbs lbs lbs trouble trouble
31. Weight gain 1 2 3 4 5 1 2 3 4 5
32. Weight loss 1 2 3 4 5 1 2 3 4 5

36
 APPENDIX 16

Screening Tools: Medication / Medical Related Issues

Known kidney problem? Y N Unusual bleeding or bruising? Y N

Frequent urinary infections? Y N Anaemia? Y N
Difficulty in urination? Y N Sores/ulcers on leg or feet? Y N
Frequent urination at night? Y N Leg pain or swelling? Y N
Known liver problems/hepatitis Y N Thyroid problems? Y N
Trouble eating certain food? Y N Known hormone problems? Y N
Nausea or vomiting? Y N Arthritis or joint problems? Y N
Constipation? Y N Muscle cramps? Y N
Diarrhoea? Y N Muscle pain/aches if weakness? Y N
Bloody or black bowel movement? Y N Memory problems? Y N
Abdominal pain or cramps? Y N Dizziness? Y N
Frequent heartburn/indigestion? Y N Hearing or visual problems? Y N
Stomach ulcer in the past? Y N Frequent headaches? Y N
Shortness of breath? Y N Rash or hives? Y N
Coughing up phlegm or blood? Y N Change in appetite or taste? Y N
Chest pain or tightness? Y N Dry mouth? Y N
Fainting spells or passing out? Y N Walking or balance problems? Y N
Thumping or racing heart? Y N Other problem? (details) Y N
Other problems: If yes, please specified:
1.

2.

3.

4.

37
 APPENDIX 17
Medication Appropriateness Index (MAI)

To assess the appropriateness of the drug, please answer the following questions and circle the
applicable score:

1. Is there an indication for the drug? 1 2 3 9

Comments: Indicated Not Indicated DK*

2. Is there medication effective for the condition? 1 2 3 9

Comments Effective Ineffective DK

3. Is the dosage correct? 1 2 3 9

Comments: Correct Incorrect

4. Are the directions correct? 1 2 3 9

Comments: Correct Incorrect DK

5. Are the directions practical? 1 2 3 9

Comments: Practical Impractical DK

6. Are there clinically significant drug-drug

1 2 3 9
interactions?

Comments: Insignificant Significant DK

7. Are there clinically significant drug-disease/

1 2 3 9
condition interactions?

Comments: Insignificant Significant DK

8. Is there unnecessary duplication with other

1 2 3 9
drug(s)

Comments: Necessary Unnecessary DK

9. Is the duration of therapy acceptable? 1 2 3 9

Comments: Acceptable Unacceptable DK

10. Is the drug the least expensive alternative

1 2 3 9
compared to others of equal utility?

Comments: Least
Most expensive DK
expensive

Total

*DK: Don’t Know

38
 APPENDIX 18
Guide to Drug Therapy in Patients with Enteral Feeding Tubes

A. Consideration in medication administration via enteral feeding:

• Suitability of dosage form, availability of alternative drugs/form or can the
physical form be altered
• Physical and chemical compatibility with enteral feed
• Complicating factors that may affect the absorption or clearance of the drug

B. Recommendation for enteral drug administration:

1. Is an alternative route of drug administration available? Would this be more
appropriate?
2. Select the most applicable dosage form for administration via the enteral
feeding tube.
3. Is there a more suitable dosage form available in an alternative drug?
4. Simplify the medication regimen.
5. Prepare the selected dosage form for administration
6. Confirm compatibility with the enteral formula before administering
medications via the feeding tube. Never add medications directly to the enteral
formula.

39