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Fairleigh Dickinson University
School of Pharmacy
Assignment #1: Prescription Label Assessment
Student:
Site:

___________________________ ______________________
Date:
__________________________

Preceptor Signature: ______________ Print Name: ___________________________
1. Items on the prescription label that are required by New Jersey State Law:

2. Items on the prescription label that are not required by New Jersey State Law:

3. Overall opinion as to the overall appearance and acceptability of the label in your pharmacy:

4. Reference(s) used for this assignment:

.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment

Student: ______________________
Site: _________________________

Date: _____________________
Print Name: ________________

Preceptor Signature ___________________
Please use the respective forms on the following pages to complete this assignment:
1. Category 1: Cough/Cold and Allergies (REQUIRED)
Reference(s) used for this assignment:

2. Category 2: Women’s Health (REQUIRED)
Reference(s) used for this assignment:

3. Category 3: Please indicate the category you chose for this assignment.(Select ONE of the following: Pain/Fever; Constipation/
Diarrhea; Heartburn/Dyspepsia; Smoking Cessation)

Reference(s) used for this assignment:

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)

Cough/Cold and Allergy Products (REQUIRED):
1. List the 4 most common active ingredients in cough, cold, and allergy products and complete the table below:
Active Ingredient

Uses/Indications

Warnings/Precautions

2. List the dosage ranges, and maximum doses of the above ingredients for both adults and children:
Active Ingredient

Dosage Range
Adult
Child

Max Dose
Adult
Child

3. The Combat Methamphetamine Act of 2005 places limits on sales of products that contain an active ingredient found in OTC cough, cold, and allergy products.
Identify this active ingredient, and discuss the specific legal requirements of this
Act, including who may purchase this product, maximum quantity that may be sold, and required documentation. Please provide a reliable reference.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)

OTC Women’s Health Products-Vaginal Yeast Infection/UTI/Contraception
(REQUIRED):
1. List 3-4 categories of vaginal yeast infection products available OTC and complete the table below.
Category

Active Ingredient

Uses/Indications

Warnings/Precautions

2. What questions do you ask a patient before recommending a product for yeast infection?

3. What can you recommend to a patient who complains of pain from a UTI?

4. What are the laws in NJ State pertaining to dispensing Plan B in the community pharmacy as an OTC? Please provide a reliable reference.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)
**SELECT 1 of the FOLLOWING 4 CATEGORIES**

Heartburn and Dyspepsia:
1. List 3-4 categories of heartburn and dyspepsia agents available OTC and complete the table below
Category

Active
Ingredient

Uses/Indications

Warnings/Precautions

2. What are some common side effects of each listed product above?

3. What questions do you ask a patient who complains of heartburn or dyspepsia?

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)

Constipation/Diarrhea:
1.

List 3-4 categories of laxatives available OTC and complete the table below.

Category

Active
Ingredient

Uses/Indications

Warnings/Precautions

2. What are some common side effects of these laxatives?

3. What questions do you ask a patient who complains of constipation?

4. List 2 categories of anti-diarrheal agents available OTC and complete the table below:
Category

Active
Ingredient

Uses/Indications

Warnings/Precautions

5. What are some common side effects of the above anti-diarrheal agents?

6. What questions do you ask a patient who complains of diarrhea?

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)

Pain/Fever:
1. List 3-4 categories of analgesic/antipyretic agents available OTC and complete the table below
Category

Active
Ingredient

Uses/Indications

Warnings/Precautions

2. What are some common side effects of the analgesics/antipyretics

3. List the dosage ranges, and maximum doses of the above ingredients for both adults and children:
Active Ingredient

Dosage Range
Adult
Child

Max Dose
Adult
Child

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #2: Over-the-Counter Medication Assignment (cont.)

Smoking Cessation:
1. List 3 nicotine replacement products available OTC.
Brand Name

Active Ingredient

Instructions for
Use

Warnings/
Precautions

2. What are some common side effects of each listed product above?

3. What are the laws and restrictions pertaining to the sale of OTC nicotine replacement products in New Jersey State? Please provide a reliable reference.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #3: Reflective Essay of Insurance Coverage and Health Disparities

Student: ________________________
Site:___________________________

Date: ____________________
Print Name: ______________

Preceptor Signature:
To complete this assignment, observe a pharmacist intervention related to prescription medication coverage.
Research the associated insurance plan and compose a reflection essay including the name and type of insurance plan coverage, the type of issue the pharmacist was intervening upon, and the impact of this intervention on patient care and costs of care. Write a reflective essay on your observations and findings relative to the impact on patient care and costs.

The reflection essay should be composed on an additional piece of paper and attached to the completed assignment packet.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #4: Patient Profile Reflective Essay

Student: _____________________
Site: ________________________

Date: ____________________
Print Name: _______________

Preceptor Signature:___________________
1.

Describe the overall key features and components of the patient profile system used at the practice site.

2.

Develop a 1-page reflective essay on the way in which the patient profile assisted you (the student) in providing an intervention in order to improve patient care and medication safety. Include in the reflection a discussion on the way in which this experience will impact your future pharmacy practice skills.

The reflection essay should be composed on an additional piece of paper and attached to the completed assignment packet.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #5: Controlled Substance Assignment

Student: _____________________

Date: ______________________

Site: ________________________

Print Name: _________________

Preceptor Signature:___________________
1. List two medications for each controlled substance class available in the community pharmacy practice site and the therapeutic use for each according to the package insert. Be sure to note the controlled substance classification for each medication as well. Schedule
II

1.

2.

2.

1.

1.

1.

2.

IV

1.

Therapeutic Use
1.

2.

III

Brand Name

Generic Name

2.

2.

1.

1.

1.

2.

2.

2.

V

1.

1.

1.

2.

2.

2.

2. List the items required on a written CII prescription by New Jersey State regulations.

3. List the items that can be added and/or changed on a written CII prescription by the pharmacist with and/or without physician’s authorization and the items that can never be added or changed.
a.) Added without physician’s authorization:

b.) Added with physician’s authorization:

c.) Never added:

d.) Changed without physician’s authorization:

e.) Changed with physician’s authorization:

f.) Never changed:

4. Cite the reference used to complete this assignment. The source may be in print or electronic form, but should be current and a respected source.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #6: Drug Interaction Alert Assignment

Student: _________________________

Date: __________________

Site:___________________

Print Name:________________

Preceptor Signature:_________________

1. Describe, in detail, the prescription that was being filled when an alert for a potential Drug Interaction was prompted. The student should include any relevant information about the patient such as concurrent medical conditions, medications, and age, as well as all of the information on the prescription with the exception of patient identifying information.

2. Document the alert verbatim as it appears on your screen

3. Describe the mechanism for the Drug Interaction being presented. The student is to research, in a reputable source, the mechanism for the interaction.

4. Compare information on the interaction severity rating with at least two reputable sources (e.g. Lexi-Comp, Drug Facts and Comparisons, Micromedex, Clinical
Pharmacology) and describe whether you (the student) agree with the severity of the interaction as it pertains to the patient for whom the prescription is being filled.

5. Describe the management/recommendation for this Drug Interaction. The student is to describe how this interaction should be managed and/or what the outcome was. If the management required physician’s approval please document the conversation and outcome.

6. Site the reference(s) used to complete this assignment. The source may be in print or electronic form, but should be current and a respected source.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #7: Interventions Documentation

Student: ________________

Date: _______________

Site:____________________
Preceptor Signature:_________________ Print Name:__________________

Using the attached Intervention Documentation form, please document five (5) clinical interventions. Suggested categories of interventions are listed below:
1. Indication
2. Length of therapy
3. Drug/drug, drug / food, or drug / lab interaction
4. Toxicity management
5. Therapeutic duplication
6. Teratogenicity /breast feeding
7. Medication identification
8. Compatibility /stability
9. Clarification of quantity to be dispensed
10. Clarification of frequency
11. Clarification of dose
12. Clarification of administration route
13. Recommendation of alternative agent
14. Recommendation of alternative route
15. Formulary/ non-formulary issue
16. Drug information need
17. Other (specify)
For each intervention provide the date of the intervention, intervention category (see above), a summary of the question/problem/issue (include details such as strengths, directions, duration where necessary), response to intervention, and references utilized.
Preceptors must verify the completion of each intervention.

Fairleigh Dickinson University
School of Pharmacy
Assignment #7: Interventions Documentation (cont.)

Intervention Documentation Form
Intervention 1
Date of Intervention
Intervention Category
(See previous page)

Question/Problem

Response

Reference

Preceptor’s Signature

Intervention 2

Intervention 3
Date of Intervention
Intervention Category
(See previous page)

Question/Problem

Response

Reference

Preceptor’s Signature

Intervention 4

Intervention 5
Date of Intervention

Intervention Category
(See previous page)

Question/Problem

Response

Reference

Preceptor’s Signature

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #8: Verbatim Patient Counseling Assessment

Student: _____________________

Date: ______________

Site: ________________________
Preceptor Signature: ___________________ Print Name: __________________
1. Describe the EXACT manner – that is, word-for-word or verbatim description – in which you (the student) would counsel a patient receiving a prescription product using the attached Indian Health Service Counseling Model. You must use an appropriate technique (such as the use of open-ended questions) as well as appropriate content for this patient-care exercise. References should be used and cited. PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #8: Verbatim Patient Counseling Assessment (cont.)

Patient Counseling Guidelines
Prescription Medication and Products
Patient counseling has been shown to be most effective when the pharmacist uses open-ended questioning to ask the patient about his/her medications. The Indian Health
Service developed a checklist of open-ended questions to facilitate patient counseling on new and refill prescriptions. Please refer to the checklist below when counseling patients in the community pharmacy.
New Prescriptions
Indian Health Service Counseling Model checklist for new prescriptions:
1) What did the doctor tell you the medication is for?
What problem or symptom is it supposed to help?
What is it supposed to do?
2) How did your doctor tell you to take the medication?
How should you take your medication (special instructions for eye drops, asthma inhalers/devices, injectables, etc.)
How much?
How long?
How often?
What did the doctor say to do if you missed a dose?
How should you store your medication?
3) What did the doctor tell you to expect?
What good effects, bad effects, precautions to take?
What should you do if a bad reaction occurs?
4) Just to make sure that I didn’t leave anything out, please tell me how you are going to take your medication?
Prescription Refills
Indian Health Service “show and tell” counseling method for prescription refills:
1) What do you take this medication for?
2) How do you take it?
3) What kinds of problems are you having?

Fairleigh Dickinson University
School of Pharmacy
Assignment #9: Self-Care Intervention

Student: ____________________
Site: _______________________

Date: __________________
Print Name: ______________

Preceptor Signature:_______________

Who is the product for?
Sex:

M

F

Self

Child

Pregnancy/Lactating:

Other:
Y

N

Age of patient (if pediatric patient, need exact age and/or weight
1) Describe the patient’s symptom(s) using the SCHOLAR mnemonic (see attached sheet for reference):
a. Symptoms:

b. Characteristics:

c. History:

d. Onset:

e. Location:

f.

Aggravating factors:

g. Remitting factors:

2) List other coexisting disease states, conditions, allergies, or medications, using the
MAC mnemonic (see attached sheet for reference):
a. Medications

b. Allergies

c. Conditions

3) What was the outcome of your self-care consultation?

Referral to primary care provider: Why?

No recommendation necessary, the condition is self-limiting.

Recommended an OTC product (please include name of product, dose, instructions for use, adverse effects, warnings and any other pertinent information): PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #9: Self-Care Intervention (cont.)

QuEST and SCHOLAR Process for Counseling Self-Care Patients
Quickly and accurately assess the patient
• Ask about current complaint (SCHOLAR)
• Ask about other medications and other products
• Ask about coexisting conditions and allergies
Establish that the patient is an appropriate self-care candidate
• No severe symptoms
• No symptoms that persist or return repeatedly without an identifiable cause
• No self-treating to avoid medical care
Suggest appropriate self-care strategies
• Medication
• General care measures
Talk with the patient
• About medication action
• About administration
• About adverse effects and how to manage them
• About what to expect from treatment
• About appropriate follow-up
Symptoms:
Characteristics:
History:
Onset:
Location:
Aggravating factors:
Remitting factors:
Medications:
Allergies:
Conditions:

What are the main and associated symptoms?
What are the symptoms like?
What has been done so far
Has this happened in the past?
When did it start?
Where is the problem?
What makes it worse?
What makes it better?
Prescription and nonprescription medications, and natural products Medication and other type of allergies
Other medical conditions

Buring SM, Kirby J, Conrad WF. A structured approach for teaching students to counsel self-care patients. Am J Pharm Educ. 2007 February 15; 71(1): 08.

Fairleigh Dickinson University
School of Pharmacy

Assignment # 10: Prescription Medication Dispensing Assessment
Student: ________________

Date: ____________________

Site: __________________
Preceptor Signature ________________

Print Name: ________________

1. The student pharmacist is to discuss the dispensing process with the preceptor. In addition, the student is to describe two (2) products that he/she helped to dispense that were particularly noteworthy. The following are some reasons for a product being noteworthy: a unique new product recently approved by the FDA, a new dosage form recently approved by the FDA, represents a change in therapy suggested by the student pharmacist or pharmacist, or a product that requires special monitoring/patient counseling.
a.)

Product A

b.)

Product B

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
Assignment #11: Pharmacy Workflow Reflective Essay

Student: ____________________
Site: ________________________

Date: ___________________
Print Name: __________________

Preceptor Signature ______________

1. Describe the pharmacy’s set-up and workflow from the time the patient comes to the pharmacy counter with a prescription, to the time the patient leaves with his/ her prescription. List the steps involved in filling the prescription. (Specify what information needs to be obtained from patient and/or physician, and/or third party provider if any issues were encountered during the filling process).

2. Develop a 1-page reflective essay on how the set-up and workflow of the pharmacy allowed you to effectively fill the patient’s prescription. If you were able to identify deficiencies in the workflow at your site, please provide recommendations on how you would correct them. Include in the reflection a discussion of the way in which this experience will impact your future pharmacy practice. The reflection essay should be composed on an additional piece of paper and attached to the completed assignment packet.

PRECEPTOR COMMENTS (OPTIONAL):

Fairleigh Dickinson University
School of Pharmacy
PHRM 6501 Completed Assignments Coversheet

Student:
Site:
Preceptor Name:

Date:
Timeframe:

***This coversheet MUST be submitted with your completed assignments.***

Assignment

Prescription Label Assignment (Form #1) Over the Counter Medication Assignments (Form #2) 1. Cough/Cold and Allergies
2. OTC Women’s Health
3. Selected Category
Insurance
Coverage and Health Disparities Reflection Essay (Form #3) Patient Profile Reflection Essay (Form #4) Controlled Substance Assignment (Form #5) Drug Interaction Alert Assignment (Form #6) Interventions Documentation (Form #7)

Verbatim Patient Counseling Assignment (Form #8) Self Care Intervention (Form #9) Prescription Medication Dispensing Assignment (Form #10) Pharmacy Workflow Reflective Essay (Form #11)

End of Rotation Requirements Preceptor Evaluation completed in RxPreceptor Site Evaluation completed in RxPreceptor Time Tracking correctly entered in RxPreceptor Assignments submitted to Experiential Education

Date Form/Assignment Completed Attached

(✔)

Completed (✔ )

*Failure to submit coversheet will result in the loss of one professionalism point from your final grade.

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