Standards › Standard 17 › Forms
Form · PHA-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 17.2
Purpose
Records the counselling given on a new medicine, and whether the patient understood it.
How to complete
- Record the medicine and the counselling given.
- Record the patient’s explanation back (teach-back).
- Record the high-risk flag and the pharmacist.
Checks
| Check | Entry |
|---|---|
| Patient (ID) and date | Yes |
| Medicine and dose | Yes |
| How to take it explained | Yes |
| What to expect and what to report explained | Yes |
| Understanding checked (teach-back, yes or no) | Yes |
| High-risk medicine (yes or no) | Yes |
| Pharmacist | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Medication Without Harm guidance (2017) and the WHO Good storage and distribution practices (2010). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)