Pharmacy Audit Data Collection Form Form Number Does the patient have any further questions?

ther questions? Yes No

Statin Concordance Were you able to answer those questions? Yes No
Did the patient find this discussion helpful? Yes No
Section 1: Patient Demographic Time taken to complete the review minutes
Male  Female  Preferred Language Audit developed by Hampshire and Isle of Wight LPC

Name of Statin
Age  <30  30-39  40-49  50-59  60-69  70+
Section 2: Understanding of Prescription
“Your medication is as a statin -do you know why you are
taking it?”
Desired Response: To lower my cholesterol levels in the blood which
can reduce the risk of having a heart attack
Patient knows why they are taking their medication? Yes No
If No, info provided to patient to fill information gap? Yes No
Section 3: Understanding of Medication
“Do you know how your medicine works?”
Desired Response: By reducing the production of cholesterol in the liver
which occurs mainly at night. This is why it is best to take the tablet at
night.
Patient has an understanding of how their medicine works? Yes
No
If No, info provided to patient to fill information gap? Yes No
Section 4: How to take the Medication
“How do you know take your medicine?”
Desired Response: Swallowed whole with a glass of water at the same
time each day, preferably at night.
Patient correctly describes how to take their medication? Yes No
If No, info provided to patient to fill information gap? Yes No
Section 5: Pharmacist Reinforcement
“Side effects from these drugs are rare. Some people
experience difficulty sleeping, stomach upset or a headache
which usually disappear after a few weeks. If you experience
muscle and joint pain, however, you should stop taking the
medication and see your doctor. If your sleeping is disturbed,
try taking the tablet earlier.”
Has the patient experienced any side-effects? Yes No
If Yes, are they still experiencing them? Yes No
“Treatment with this medicine is in ADDITION to a cholesterol
reducing diet – not instead of one.”
Has the patient taken steps to reduce their cholesterol intake? Yes
No
Have you offered a cholesterol reducing diet sheet? Yes No
 Form Number

Pharmacy Audit Data Collection Form Does the patient have any further questions? Yes No
Statin Concordance Were you able to answer those questions? Yes No
Did the patient find this discussion helpful? Yes No
Section 1: Patient Demographic Time taken to complete the review minutes
Male  Female  Preferred Language Audit developed by Hampshire and Isle of Wight LPC

Name of Statin
Age  <30  30-39  40-49  50-59  60-69  70+
Section 2: Understanding of Prescription
“Your medication is as a statin -do you know why you are
taking it?”
Desired Response: To lower my cholesterol levels in the blood which
can reduce the risk of having a heart attack
Patient knows why they are taking their medication? Yes No
If No, info provided to patient to fill information gap? Yes No
Section 3: Understanding of Medication
“Do you know how your medicine works?”
Desired Response: By reducing the production of cholesterol in the liver
which occurs mainly at night. This is why it is best to take the tablet at
night.
Patient has an understanding of how their medicine works? Yes
No
If No, info provided to patient to fill information gap? Yes No
Section 4: How to take the Medication
“How do you know take your medicine?”
Desired Response: Swallowed whole with a glass of water at the same
time each day, preferably at night.
Patient correctly describes how to take their medication? Yes No
If No, info provided to patient to fill information gap? Yes No
Section 5: Pharmacist Reinforcement
“Side effects from these drugs are rare. Some people
experience difficulty sleeping, stomach upset or a headache
which usually disappear after a few weeks. If you experience
muscle and joint pain, however, you should stop taking the
medication and see your doctor. If your sleeping is disturbed,
try taking the tablet earlier.”
Has the patient experienced any side-effects? Yes No
If Yes, are they still experiencing them? Yes No
“Treatment with this medicine is in ADDITION to a cholesterol
reducing diet – not instead of one.”
Has the patient taken steps to reduce their cholesterol intake? Yes
No
Have you offered a cholesterol reducing diet sheet? Yes No