Patient Counseling Rubric

Part 1 – Introduction and Patient History	Not completed	Completed	Comments
1.Greets patient (hi, hello, handshake, etc.)	0	0.5
2.Introduces self (name)	0	0.5
3.States title (i.e., student pharmacist)	0	0.5
4.Explains purpose of counseling session (best benefits/safety)	0	0.5
5.Asks permission	0	0.5
6.Confirms patient name	0	0.5
7.Confirms date of birth	0	0.5
8.Verifies phone number	0	0.5
9.Verifies address	0	0.5
10.Collects past medical history (medical conditions)	0	0.5
11.Verifies patient allergies (drug/environmental/food and reaction)	0	0.5
12.Verifies Rx medications	0	0.5
13.Verifies OTC medications	0	0.5
14.Vitamin use	0	0.5
15.Herbal supplement use	0	0.5
16.Sample medication use	0	0.5

Part 2 – Basic Counseling Points	Not completed	Completed	Comments
17.Provides medication name	0	1
18.Brand or generic medication	0	1
19.Assesses prior knowledge – what did doctor tell you this was for?	0	1
20.Provides indication for medication	0	1
21.Assesses prior knowledge – how did doctor tell you to take this?	0	1
22.Provides dose of medication	0	1
23.Addresses dosage form concerns	0	1
24.Provides regimen for medication (tailored to patient schedule)	0	1
25.Explains anticipated duration of therapy	0	1
26.Refill information	0	1
27.Assesses prior knowledge – what did doctor tell you to expect about… (side effects/expected results, etc)?	0	1
28.Efficacy – What results to expect	0	1
29.Efficacy – When to expect results	0	1
30.Provides adherence tip	0	1
31.Describes missed dose instructions	0	1
32.Gives specific time frame for missed doses	0	1
33.Common ADRs (provide at least 3)	0 1 2 3
34.Severe ADRs	0	1
35.Management of ADRs (common & severe ADRs mentioned)	0	1
36.Discusses warnings and precautions (pregnancy, alcohol, etc when applicable)	0 1 2 3
37.Discusses drug-drug interactions (need to verbalize if none)	0	1
38.Other drug interactions (disease/food interactions; skip if none)	0	1
39.Where do you store your medications? (give suggestions)	0	1
40.Store away from kids/pets	0	1
41.Beneficial non-drug activities (diet, exercise, keep appts, etc)	0	1
Part 3 – Counseling Session and Communication	Not completed	Completed	Comments
42.Checks for patient understanding (corrects, reinforces)	0	1
43.Summarizes key points (at least 3)	0	1
44.Probes for questions	0	1
45.Identifies/addresses any real or anticipated concerns (anytime)	0	1
46.Offers follow-up	0	1
47.Uses open ended questions throughout session	0 1 2
48.Logical and sequential order used	0	1
49.Patient friendly language used (no jargon)	0	1
50.Appropriate non-verbal behavior (eye contact, body language)	0	1
51.Maintains control and direction of counseling session	0	1
52.Professionalism (dress, attitude, communication)	0	1
53.Overall presentation style	0	1

Part 4 – Special Instructions (OPTIONAL SECTION)	Points Awarded	Comments
54.Special Instructions addressed (ex. Eye drops, inhalers, etc) NOTE: 2 extra minutes will be provided for device counseling	0-10