- Owner
- Pharmacist in Charge
- Effective date
- September 15, 2026
- Review cycle
- Every 12 months
1.Purpose
To make sure patients understand how to take their medication safely and effectively by offering and documenting counseling for new and changed prescriptions.
2.Scope
Applies to counseling offered at the point of dispensing for new prescriptions, significant dose changes and patient-requested consultations. Does not cover clinical medication therapy management visits.
Definitions
- Teach-back
- Asking the patient to repeat key instructions in their own words to confirm understanding.
- Medication guide
- A printed patient information leaflet required for certain medications, covering risks and instructions.
- Refusal of counseling
- A patient's documented decision to decline the offered counseling session.
3.Responsibilities
- Pharmacist
- Leads the counseling discussion, answers clinical questions and documents the session.
- Pharmacy Technician
- Offers counseling at pickup, directs the patient to the pharmacist, and prepares written materials.
- Patient
- Shares relevant health information and asks questions to confirm understanding of the medication.
RACI matrix
| Activity | Pharmacist | Pharmacy Technician | Patient |
|---|---|---|---|
| Offer counseling at pickup | I | R/A | C |
| Conduct the counseling discussion | R/A | I | C |
| Document counseling or refusal | R/A | C | - |
| Provide written medication information | C | R/A | I |
R = Responsible, A = Accountable, C = Consulted, I = Informed
4.Materials and PPE
Materials, tools and systems
- →Patient medication profile
- →Medication guides and printed information leaflets
- →Private or semi-private counseling area
- →Counseling documentation log in the pharmacy system
- →Device demonstration units (inhaler, injection pen trainers)
5.Procedure
- 5.1
Identify prescriptions requiring counseling
Pharmacy TechnicianFlag new prescriptions and significant dose or therapy changes for counseling as the order is filled, per pharmacy policy and local practice requirements.
- 5.2
Review the patient profile before the discussion
PharmacistReview the patient's medication history, allergies and any recent DUR alerts before starting the counseling session.
- 5.3
Offer counseling to the patient
Pharmacy TechnicianAt pickup, offer counseling on any new or changed prescription and direct the patient to the pharmacist if they accept.
- 5.4
Move to a private area
PharmacistConduct the discussion in the private or semi-private counseling area, out of hearing range of the general waiting area where possible.
- 5.5
Confirm identity and introduce the discussion
PharmacistConfirm the patient's identity, introduce yourself, and briefly explain the purpose of the counseling session.
- 5.6
Explain the medication and its purpose
PharmacistExplain the medication name, what it is for, and how it fits with the patient's other therapy, in plain language.
- 5.7
Review dosage and administration technique
PharmacistExplain how and when to take the medication, and demonstrate technique for devices such as inhalers or injection pens using a trainer if needed.
Checkpoint: For an injectable or inhaled device, the patient demonstrates the technique back correctly before leaving.
- 5.8
Discuss side effects and warning signs
PharmacistDescribe common side effects and the specific signs that should prompt the patient to call the prescriber or seek urgent care.
Warning: Clearly flag any side effect requiring immediate medical attention rather than a routine follow-up call.
- 5.9
Cover interactions and storage
PharmacistDiscuss relevant food, alcohol or drug interactions, and any special storage requirements such as refrigeration.
- 5.10
Confirm understanding with teach-back
PharmacistAsk the patient to repeat back in their own words how and when they will take the medication, and correct any misunderstanding immediately.
- 5.11
Provide written information
Pharmacy TechnicianGive the patient the medication guide or information leaflet and pharmacy contact information for follow-up questions.
- 5.12
Document the session
PharmacistRecord that counseling was offered and completed, or note a documented refusal, in the pharmacy system before closing out the prescription.
6.Quality checks
- →Counseling is offered on every new prescription before pickup is complete.
- →Documented refusals include the date and method of offer.
- →Device technique is confirmed with teach-back for injectables and inhalers.
- →Written medication information is provided alongside verbal counseling.
7.Records
- →Counseling documentation log
- →Documented counseling refusals
- →Device technique confirmation notes
- →Medication guide distribution records
8.KPIs
- →Percentage of new prescriptions with documented counseling or refusal
- →Patient-reported understanding on follow-up surveys
- →Number of callback questions received after pickup
- →Average counseling session length
9.Common mistakes
- →Skipping the offer of counseling because the pharmacy is busy.
- →Reading directions off the label instead of confirming the patient can teach it back.
- →Not documenting a patient's refusal of counseling.
- →Rushing through inhaler or injection technique without a demonstration.
10.Revision history
| Revision | Date | Description | Reviewed by |
|---|---|---|---|
| 1.0 | September 15, 2026 | Initial release | Ilia Pirozhenko |
This is a template. Adapt it to your organization, equipment and local regulations before use.
