Medicare Part D Beneficiaries' Satisfaction on Potential Process Changes Associated With Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs) (CMS-10396)

Visual Aid #2 – Medication Action Plan Mockup
Dr. Jane Doe
1500 Main Street
Anytown, MD 21201
MEDICATION ACTION PLAN FOR Mr. John Smith, DOB: 07/04/1940
This action plan will help you get the best results from your medications if you:
1.
2.
3.
4.

Read “What we talked about.”
Take the steps listed in the “What I need to do” boxes.
Fill in “What I did and when I did it.”
Fill in “My follow-up plan” and “Questions I want to ask.”

Have this action plan with you when you talk with your doctors, pharmacists, and
other healthcare providers in your care team. Share this with your family or
caregivers too.

DATE PREPARED: 01/14/2013
What we talked about:
 High Cholesterol
What I need to do:
 Monitor diet; eat fewer high
cholesterol foods (see dietary
handout for healthier options).
 Get your cholesterol checked.

What I did and when I did it:

What we talked about:
 High Blood Pressure - at visit on 1/14/2013 it was 154/92 mmHg
What I need to do:
 Check blood pressure at least 3
times a week and record on log.
 Maintain blood pressure less than
130/80 mmHg.
 Monitor salt in my diet and
increase daily exercise.
 Make an appointment with
physician to have blood pressure
rechecked and share log.

What I did and when I did it:

Form CMS-10396 (07/14)

Form Approved OMB No. 0938-1154

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Visual Aid #2 – Medication Action Plan Mockup
What we talked about:
 Diabetes
What I need to do:
 Continue to check blood sugar
once a day.
 Maintain fasting blood sugar less
than 120 and greater than 70.
 Make an appointment to see the
podiatrist within one month.

What I did and when I did it:

What we talked about:
 How to use your Metered Dose Inhaler - Albuterol
What I need to do:
 Refer to the attached handout on
proper inhaler technique.
 Always use spacer with inhaler.
 Keep this medication with me at
all times – “rescue inhaler”.

What I did and when I did it:

My follow-up plan (add notes about next steps):

Questions I want to ask (include topics about medications or therapy):

If you have any questions about your action plan, call Dr. Jane Doe at 1-800-2223333 between the hours of 9am and 5pm, Monday through Friday.

Form CMS-10396 (07/14)

Form Approved OMB No. 0938-1154

Page 2 of 2