HumanisRx - BPMH

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

HumanisRx - Best Possible Medication History

FIRST NAME: [First name]
LAST NAME: [Last name]
DATE OF BIRTH: [yyyy-mm-dd]
GENDER: [Gender]

SOURCES OF INFORMATION:
(hyphenated list)
- [Patient]
- [Family]
- [Caregiver]
- [Community pharmacy]
- [Prescriber]
- [Electronic health record]
- [Other]

ALLERGIES/ADVERSE DRUG REACTIONS:
(hyphenated list)
- [Allergy or adverse reaction and description]

CURRENT MEDICATIONS:
(hyphenated list)
- [Medication name, dose, route, frequency, indication]
- [Comments]

CURRENT SELF-PRESCRIBED PRODUCTS (EX OTC, VITAMINS, HERBALS):
(hyphenated list)
- [Product name, dose, route, frequency, indication]
- [Comments]

DISCONTINUED MEDICATIONS/PRODUCTS:
(hyphenated list)
- [Medication/product name, dose, route, frequency, indication, date discontinued]
- [Comments]

Pharmacist name: [Pharmacist name]
Date: [Date]
Licensing province: [Licensing province]
Phone: [Phone number]
Email: [Email address]