PRECEPTOR CHECKLIST/ SIGN-OFF

PHRM 771 Community IPPE

Teera Sujithamrak

Student Name _________________________________________________________________

Elaine Lucero

Supervising Preceptor Name(s) ___________________________________________________

Smith's Pharmacy #496

Location ______________________________________________________________________

3701 Constitution NE

Albuquerque, NM 87110

INSTRUCTIONS
The following table outlines the primary learning goals and activities for the Community
IPPE. Each student should successfully complete all items on the checklist by the end of
the community IPPE. The student should maintain the checklist and the preceptor should
review the checklist at the beginning of the rotation and regularly thereafter (at least
weekly). When a student successfully completes an item on the checklist, the preceptor
should initial and date the item.
DO NOT wait until the last week of the rotation to begin having items checked off.
1. Activities beyond discussion and observation must be documented by the student. For those
activities that do not have a designated form, the student should record the assignment results
using a word-processing program.
2. All documentation of assignment completion must accompany the completed check list to
earn full credit for the rotation.
Student to submit a hard copy of completed checklist and the supporting documentation
to the Office of Experiential Education no later than August 17th 2015 (or January 25th
2016 for winter schedule).

Community IPPE Checklist

Objective 1.1
Describe the scope of the practice and the functions, roles and accountabilities of its personnel as they relate
to pharmacy services and practice management. (Competency 4.2)
Observe and discuss the following with the preceptor (ideally during week #1):
Number, roles and accountabilities of (functions performed and skills needed by) pharmacists,
technicians and other personnel
Reporting relationships within the site and company
Services offered by the practice
Workload (e.g. numbers of prescriptions filled per day, impact of third party plans) and work processes
Objective 1.2
Relate the characteristics of the patient base and population of the surrounding community to the provision of
and need for pharmacist-provided services. (Competency 6.2)
Discuss with the preceptor aspects of the patient-centered pharmacist-patient relationship (ideally during
week #1)
Appropriate sharing of power and responsibility between the pharmacist, patient and caregivers
Importance of open and honest communication between pharmacist and patient
Influence of age, cultural sensitivity, health literacy and respect for the patients individuality, emotional
needs, values, and life issues in achieving an effective pharmacist-patient relationship, both in gathering
information and in achieving patient adherence to prescribed therapy and/or prevention and health
promotion strategies
Relationship of the community pharmacy approach to the establishment of the pharmacist-patient
relationship, continuity of care, and health promotion and disease prevention
Observe and discuss with the preceptor community demographics and the patient base at this site, including
age range, ethnicities, level of education, predominant occupations, socio-economic status, and predominant
disease states (ideally during week #1 or #2)
Objective 2.1
Describe and apply legal regulations and workflow, policies, and procedures used to ensure the provision of
safe and effective drug products. (Activities below may be completed at any time during rotation)
(Competency
7.1 & with
4.1) the preceptor the legal requirements for dispensing prescription medications,
Review and discuss
including those for controlled substances
Review and discuss with the preceptor the legal and ethical principles governing the maintenance and
communication of patient information/ medical records.
Outline the legally required components of NM Board of Pharmacy regulations for patient counseling.
Observe and describe how these components are utilized at practice site. Discuss key points of patient
counseling.

Student

Preceptor

Date

Student

Preceptor

Date

Student

Preceptor

Date

Community IPPE Checklist

Observe pharmacists and pharmacy technicians through their daily activities then review and discuss with the
preceptor the policies and workflow processes used in the practice to
order and manage inventory of medications
store medications
verify prescription authenticity and accuracy
to maximize efficiencies and minimize medication-related errors when dispensing prescriptions
Identify five (5) medications used in the practice that are NOT stored at room temperature and five (5)
medications given by a non-oral route of administration. List the specific storage requirements for the 5
medications not stored at room temperature and describe why these are necessary. For 5 medications not
taken by mouth, identify the route of administration and reason(s) why the medication is administered by a
non-oral route as well as proper patient counseling for those medications. Record results for inclusion with
this report.
Discuss with preceptor the policies and procedures (workflow, checks and balances) used to ensure provision
of appropriate, safe and effective drug products to patients. Include in your discussion how the responsibilities
and liabilities differ for pharmacists and technicians in the medication use system as well as the attitudes or
behaviors that can contribute to unsafe practices.
Objective 2.2
Participate in the appropriate acquisition, storage and inventory management of prescription and nonprescription medications. (Activities below may be completed at any time during rotation) (Competency 4.1)
Participate in the process of ordering medications from a wholesaler or other supplier. Where possible, this
should include completion of forms necessary to acquire controlled substances.
Participate in the process of checking in and storing products delivered to the practice site.
Fill out a DEA 222 form
Follow companys protocol to perform inventory on CII substances.
Review how to document discrepancies in controlled substances.
Discuss with preceptor how to handle employee theft of controlled substances or any medication.
Objective 2.3
Process and dispense prescription medications in accordance with legal regulations and policies and
procedures of the practice. (Activities below may be completed at any time during rotation) (Competency 1.5)
Follow at least five(5) new and five(5) refill prescriptions from intake through the steps necessary to
appropriately dispense that prescription. Where possible, these should include at least one each of the
following
controlled substance prescription
compounded prescription
receive prescription phoned in by physicians office
request for clarifying information and/or prescription refill approval from a physicians office

Student

Preceptor

Date

Student

Preceptor

Date

Community IPPE Checklist

Perform calculations necessary to compound, dispense a prescription, or deliver a medication dose for a
minimum of five(5) prescriptions
Where available, demonstrate appropriate compounding technique. We recognize that some sites do not
provide this service.
Check prescriptions filled by pharmacy technicians on at least five(5) occasions
Objective 3.1
Conduct Patient Interviews (Activities below may be completed at any time during rotation) (Competency 1.1)
Interview a minimum of two patients to obtain patient specific information necessary for the appropriate
dispensing and use of medications. One interview should be with a patient filling a new prescription and a
second to assess compliance with and effectiveness and safety of a current medication at the time of refill.
Conduct appropriate patient and physical assessment to assess need for or response to drug therapy (e.g.
observation of patient appearance / behavior, pulse, blood pressure) for a minimum of two patients (may be
the same patients for whom interview is conducted).
Objective 3.2

Student

Preceptor

Date

Student

Preceptor

Date

Identify and Resolve Drug Related Problems (Activities below may be completed at any time during
rotation) (Competency 3.3)
Discuss with the preceptor ways in which data are systematically collected and analyzed to identify and
address drug-related problems
Discuss with the preceptor how automated alerts for drug interactions or duplication of therapy are
handled in the practice.
With the preceptor, communicate with patients and/or review of patient medication records to identify a
minimum of five(5) actual or potential drug- related problems
1

DRPs may include compliance issue (over or underuse); adverse drug reaction (actual or potential); drug selection problem (no drug for identified condition, drug
with no identified condition, inappropriate/ suboptimal drug selection); drug regimen problem (inappropriate dose, dosage form or route of administration); drugdrug, drug-disease, or drug-food interaction (actual or potential).

Objective 3.3
Evaluate and respond to drug information inquiries (Ideally completed during week #3 but must be completed
by last day of rotation). (Competency 5.1)
Clarify, research and respond to a minimum of 2 drug information questions including the identification of
appropriate references. With preceptor guidance, identify two drug information questions; one from a patient
and one from a health care provider and
outline an appropriate search strategy for each
identify appropriate resources
evaluate literature resources
prepare and submit a written response using the DI documentation form

Student

Preceptor

Date

Community IPPE Checklist

Objective 4.1
Provide patient counseling for the use of prescription medications and related drug delivery or self-monitoring
devices (Note: if you dont see a patient like this, talk to your preceptor about a preceptor-led demonstration.
activities below may be completed at any time during rotation). (Competency 1.5)
Provide prescription medication use counseling, consistent with NM Board of Pharmacy. Requirements, for a
minimum of 5 patients
Teach patients to use drug delivery or self-monitoring devices, including (where possible) but not limited to
subcutaneous injections (e.g. measuring, mixing, and injecting insulin products)
metered-dose and dry powder inhalers
blood glucose meters
peak flow meters

Student

Preceptor

Date

Objective 4.2
Consult with Patients Regarding Non-prescription Product Selection and Use (Activities below may be
completed at any time during rotation) (Competency 1.5)
Walk the OTC drug aisles and review OTC products.
Conduct triage and provide self-care recommendations for a minimum of 4 patients. Document your
interactions using the Self-Care Documentation Form and provide copies to your preceptor for review.
Objective 5.0
Document pharmacists activities, interactions and interventions with patients. (Competency 3.3)
Use inventory / information management tools to document the acquisition and distribution of prescription and
non-prescription medications and devices at least once.
Use prescription processing / dispensing software system to maintain accurate of patient information and
dispensing records for a minimum of five (5) patient encounters.
Adjudicate third-party payment claims for a minimum of five (5) prescriptions or patient care services.

Student

Preceptor

Date

Student

Preceptor

Date

Identify and document a minimum of five actual or potential drug-related problems identified through review
of patient medication records and any corrective actions taken.
Observe patient-pharmacist self-care (OTC) communications, interventions and recommendations for a
minimum of one (1) patient.
Observe patient-pharmacist MTM communications, interventions and recommendations for a minimum of
one (1) patient.

Community IPPE Checklist

Objective 6.0
Promote public health and disease prevention (activities below may be completed at any time during rotation)
(Competency 2.3)
Assigned Reading
Read Using Health Observances to Promote Wellness in Community Pharmacies (J Am Pharm Assoc.
2003, 43:61-68) at http://japha.org/article.aspx?articleid=1035903

Student

Preceptor

Date

Student

Preceptor

Date

Discuss with preceptor opportunities to promote patients health through education and screenings as well as
obstacles that may be encountered. Discuss with preceptor your plans for a future event (community outreach
or education offering) that can be incorporated into community pharmacy.
Discuss with the preceptor the current efforts of the practice to promote population-based health maintenance
and disease prevention.
Identify and research at least five (5) community resources/agencies in your community/area with which
pharmacists might interact. For each agency, provide contact information, a brief summary of what they do
and how they help patients.
Objective 7.0
Demonstrate mature and professional attitudes, habits and behaviors (activities below may be completed at any
time during rotation) (Competency 7.3)
Assigned Reading
Review the professionalism white paper (Pharmacotherapy 2009;29(6):749756) Development of Student
Professionalism (HSLIC electronic journals) and print a copy for your preceptor. Discuss with preceptor
opportunities to promote professionalism at your practice site as well as obstacles that may be encountered.

Review the preceptor sign-off / checklist with preceptor on the first day of the rotation and weekly thereafter.
Make sure all items are checked off by the last day of the rotation.

Drug Information Documentation Form

State the question received:
1. Identify requestor

2. Why is the question being asked?

3. Formulate clear and specific drug information question(s).

4. Classify drug information request by selecting all that apply.

Adverse effect
Availability
Compatibility/stability
Cost analysis
Dose/dosage/administration
Drug identification
Drug interaction

Drug compatibility/stability
Drug therapy
Patient Education
Pregnancy/lactation
Pharmacy practice
Pharmacology
Other _____________

5. Describe your strategy for conducting a systematic strategy and cite references used.

6. Explain your process of resource evaluation and analysis. Provide a concise substantiated
conclusion from the resources used.

7.

Provide response to the question.

Drug Information Documentation Form

State the question received:
1. Identify requestor

2. Why is the question being asked?

3. Formulate clear and specific drug information question(s).

4. Classify drug information request by selecting all that apply.

Adverse effect
Availability
Compatibility/stability
Cost analysis
Dose/dosage/administration
Drug identification
Drug interaction

Drug compatibility/stability
Drug therapy
Patient Education
Pregnancy/lactation
Pharmacy practice
Pharmacology
Other _____________

5. Describe your strategy for conducting a systematic strategy and cite references used.

6. Explain your process of resource evaluation and analysis. Provide a concise substantiated
conclusion from the resources used.

7.

Provide response to the question.

Drug Information Instructions:

These instructions are a guide to completing the Drug Information Worksheet. Responses should
be concise with sufficient detail to show the thoroughness of the search and appropriateness of the
final response to the requestor. Additional guidance can be found in Access Pharmacy Database
Drug Information: A Guide for Pharmacists
The worksheet should not exceed 2 pages in length.
1. Obtain information on the requestor. The individual professional credentials (physician, pharmacist,

nurse, physician assistant, dentist, or lay person- patient/caregiver) suggest educational experience
and knowledge. This can be used to determine the appropriate level to formulate and deliver the
response to the question(s).
2. Determine why the question is being asked. What information is sought? Is it a specific patient or a

general question? Is the question prospective or retrospective? Is the question for general information
or to reach a clinical decision? This information is helpful in formulating the question(s) to be
addressed.
3. The question must be carefully focused to address the specific information needed to address the

particular situation. All pertinent/relevant factors must be included patient, clinical situation etc.
Examples:
Not Focused: What is the dose of amoxicillin? There is not enough information here to answer a
clinical question, or address a specific patient needs.
Focused: What is the dose and frequency of amoxicillin before a dental procedure for bacterial
endocarditis prophylaxis in an 18 year old male? The question addresses a specific scenario and
allows the response to be focused.
4. Classifying the question allows for selection of the appropriate resource. Selecting the right

reference focuses the search strategy and increases likelihood of locating the correct response.
See list of suggested references for guidance.
5. List the resource(s) that you selected for the search based on the probability of locating the requested

information. These should be prioritized based on your knowledge of what information is most likely
to be found in a particular reference. Alternatively, you may have selected resources based on ease of
access or your comfort in use. If so, state such. Provide your search strategy this can be done via cut
and paste of the URL or typed out [e.g. PubMed: pediatric + ear infection]
Describe how you conducted a systematic search. A logical progression is to begin with the
information located within the tertiary literature and then move to secondary/primary to fine tune
information. If you use secondary literature to access the primary literature, briefly list your search
terms. The description should include the confirming reference(s) used to format the response.
When applicable, the use of non-standard references may be used provided they are critically
analyzed for credibility. Use of such resources must be explained including the critical analysis.
These may include websites or non-referee journal publications.
Cite your references using AMA style as found at http://www.docstyles.com/amaguide.htm . All
references used in the final answer should be listed. Include any confirming information as well as
the original article/reference.

6. Evaluate and analyze the findings and confirm with other references for appropriateness, accuracy

and reliability. Is the reference current and supported by other references? In instances where
conflicting information is found, provide an evaluation and analysis of how you selected the best
reference to be used for this specific question.
7. Synthesize your findings in to a single comprehensive conclusion. Response should show

thoughtfulness and applicability to the question asked. Response should explain why one
reference was selected over another when appropriate.
Prepare a concise (less than 100 words) response to the requestor. Begin the response by
answering the question. Provide more details as needed. Compose the response at the
comprehension level of the requestor. References should be incorporated into the final response.
Helpful Hints for Answering Drug Information Questions
It is acceptable to begin with a tertiary resource for background data. If you begin with a tertiary
reference, review any cited primary literature. The presented may not fully represent the entire primary
reference. Many questions will require a literature search even if you find an answer in a tertiary
reference. When doing a literature search, be sure to review older data if available. Just because the
information is older does not mean that it is not relevant or useful.
Any resource information should be double checked against another reference to establish credibility.
A review of cited primary literature is often effective in establishing a credible response.
When using clinical guidelines, verify that the guidelines are supported by a professional organization.
Confirm that the guidelines selected are the most recent AND are those most appropriate for this
specific question. When guidelines conflict, perform an evaluation to determine the best answer.
Both safety and efficacy data are important when reviewing a drug therapy. If your
reference(s) do not address these, comment within your final response. Consider adding
common side effects/uses or populations in whom the drug should not be used.
Always answer the question in the first sentence of the written response.
The final response should be complete such that the person asking the question could treat a
patient immediately with the information you provide. Dosage information and/or a brief
summary of the efficacy/safety data should be provided.

Self-Care Documentation Form

Patient Information:
Initials: __________

Male

Female

Pregnant

Patient Age:

< 2 years

217 years

18-64 years

Breastfeeding
65 years

Describe chief complaint:

Area of Chief Complaint:
Allergy
Cold
Constipation
Cough
Dermatology
Diarrhea

Headache
Heartburn
Fever
Ophthalmic
Otic
Tobacco cessation
Other __________________

Patient Assessment
Suggested questions to focus chief complaint:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Symptoms: What are the main and associated symptoms?

Characteristics: What is the situation like? Is it changing?
History: What has been tried so far? Have you had this before?
Onset: When did it start?
Location: Where is the problem located?
Aggravating Factors: What makes it worse?
Remitting Factors: What makes it better?
Medications: Are you taking any prescription or non prescription drugs? Herbal products, vitamins
or dietary supplements?
Allergies: Do you have any allergies to food or medication? If so, what are they?
Coexisting conditions: Do you have any other medical conditions or health problems?

Patient Analysis
1. List the issues identified.
2. Assessment of current medication therapy (if applicable)
3. Assessment of current medical condition.
4. Treatment goals:
Patient is a self-care candidate
Refer patient to _________________ due to _______________________________________.

Possible Self-Care Strategies

Possible General care measures:

Possible non-prescription medication: (list all options and justifications)

Recommendations to Patient
General care measures recommended:

Non-prescription medications recommended. (Include name, strength, route, frequency & duration)

Patient education (i.e., medication administration technique, adverse effects, expectations, monitoring).

Student Name: ____________________________________________

Date: ___________________

Reviewed by Pharmacist: _________________________________

Date: ___________________

Retain copy in work book.

10

Self-Care Documentation Form

Patient Information:
Initials: __________

Male

Female

Pregnant

Patient Age:

< 2 years

217 years

18-64 years

Breastfeeding
65 years

Describe chief complaint:

Area of Chief Complaint:
Allergy
Cold
Constipation
Cough
Dermatology
Diarrhea

Headache
Heartburn
Fever
Ophthalmic
Otic
Tobacco cessation
Other __________________

Patient Assessment
Suggested questions to focus chief complaint:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Symptoms: What are the main and associated symptoms?

Characteristics: What is the situation like? Is it changing?
History: What has been tried so far? Have you had this before?
Onset: When did it start?
Location: Where is the problem located?
Aggravating Factors: What makes it worse?
Remitting Factors: What makes it better?
Medications: Are you taking any prescription or non prescription drugs? Herbal products, vitamins
or dietary supplements?
Allergies: Do you have any allergies to food or medication? If so, what are they?
Coexisting conditions: Do you have any other medical conditions or health problems?

Patient Analysis
1. List the issues identified.
2. Assessment of current medication therapy (if applicable)
3. Assessment of current medical condition.
4. Treatment goals:
Patient is a self-care candidate
Refer patient to _________________ due to _______________________________________.

Possible Self-Care Strategies

Possible General care measures:

Possible non-prescription medication: (list all options and justifications)

Recommendations to Patient
General care measures recommended:

Non-prescription medications recommended. (Include name, strength, route, frequency & duration)

Patient education (i.e., medication administration technique, adverse effects, expectations, monitoring).

Student Name: ____________________________________________

Date: ___________________

Reviewed by Pharmacist: _________________________________

Date: ___________________

Retain copy in work book.

10

Self-Care Documentation Form

Patient Information:
Initials: __________

Male

Female

Pregnant

Patient Age:

< 2 years

217 years

18-64 years

Breastfeeding
65 years

Describe chief complaint:

Area of Chief Complaint:
Allergy
Cold
Constipation
Cough
Dermatology
Diarrhea

Headache
Heartburn
Fever
Ophthalmic
Otic
Tobacco cessation
Other __________________

Patient Assessment
Suggested questions to focus chief complaint:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Symptoms: What are the main and associated symptoms?

Characteristics: What is the situation like? Is it changing?
History: What has been tried so far? Have you had this before?
Onset: When did it start?
Location: Where is the problem located?
Aggravating Factors: What makes it worse?
Remitting Factors: What makes it better?
Medications: Are you taking any prescription or non prescription drugs? Herbal products, vitamins
or dietary supplements?
Allergies: Do you have any allergies to food or medication? If so, what are they?
Coexisting conditions: Do you have any other medical conditions or health problems?

Patient Analysis
1. List the issues identified.
2. Assessment of current medication therapy (if applicable)
3. Assessment of current medical condition.
4. Treatment goals:
Patient is a self-care candidate
Refer patient to _________________ due to _______________________________________.

Possible Self-Care Strategies

Possible General care measures:

Possible non-prescription medication: (list all options and justifications)

Recommendations to Patient
General care measures recommended:

Non-prescription medications recommended. (Include name, strength, route, frequency & duration)

Patient education (i.e., medication administration technique, adverse effects, expectations, monitoring).

Student Name: ____________________________________________

Date: ___________________

Reviewed by Pharmacist: _________________________________

Date: ___________________

Retain copy in work book.

10

Self-Care Documentation Form

Patient Information:
Initials: __________

Male

Female

Pregnant

Patient Age:

< 2 years

217 years

18-64 years

Breastfeeding
65 years

Describe chief complaint:

Area of Chief Complaint:
Allergy
Cold
Constipation
Cough
Dermatology
Diarrhea

Headache
Heartburn
Fever
Ophthalmic
Otic
Tobacco cessation
Other __________________

Patient Assessment
Suggested questions to focus chief complaint:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

Symptoms: What are the main and associated symptoms?

Characteristics: What is the situation like? Is it changing?
History: What has been tried so far? Have you had this before?
Onset: When did it start?
Location: Where is the problem located?
Aggravating Factors: What makes it worse?
Remitting Factors: What makes it better?
Medications: Are you taking any prescription or non prescription drugs? Herbal products, vitamins
or dietary supplements?
Allergies: Do you have any allergies to food or medication? If so, what are they?
Coexisting conditions: Do you have any other medical conditions or health problems?

Patient Analysis
1. List the issues identified.
2. Assessment of current medication therapy (if applicable)
3. Assessment of current medical condition.
4. Treatment goals:
Patient is a self-care candidate
Refer patient to _________________ due to _______________________________________.

Possible Self-Care Strategies

Possible General care measures:

Possible non-prescription medication: (list all options and justifications)

Recommendations to Patient
General care measures recommended:

Non-prescription medications recommended. (Include name, strength, route, frequency & duration)

Patient education (i.e., medication administration technique, adverse effects, expectations, monitoring).

Student Name: ____________________________________________

Date: ___________________

Reviewed by Pharmacist: _________________________________

Date: ___________________

Retain copy in work book.

10