Next-generation Medication Dispenser to Improve Care at Home for Community-dwelling Elderly
Phase: NA
Conditions: Medication Adherence, Cognitive Impairment
Sponsor: Lee Verweel

1 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
 
 
 
Title: Next-generation medication dispenser to improve 
care at home for community-dwelling elderly 
 
 
Principle Investigator:  
Tim Pauley, Manager, Research & Evaluation, West Park Healthcare Centre 
Co-Investigators:  
Audrey Sand, Manager, Evaluation and Knowledge Transfer, CapitalCare 
Corporate Services  
Document updated on: April 17, 2018 
NCT ID: Not yet assigned 
Unique Protocol ID: I2P2: AceAge 
 
 
 
 
 
 
 
 
 
 

2 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
1 INTRODUCTION 
 
The prevalence of multi-morbidity (i.e., > 2 mental and/or physical conditions) in the elderly 
population is upwards of 60% (Salive, 2013). Patients with multi-morbidity are often prescribed 
multiple medications of varying doses to be taken at different times of the day. Furthermore, 
there is considerable evidence showing that non-adherence to prescribed medications can be 
as high as 50% among the elderly, especially among those with cognitive impairment (Conn, 
Taylor, & Miller, 1994). Non-adherence can lead to mismanagement of chronic diseases and it 
increases the risk of adverse drug reactions, physician consultations, emergency room (ER) 
visits and hospitalizations (Vermeire, Hearnshaw, Van, & Denekens, 2001). Overall, these 
factors have a significant impact on the health system, health care cost and patient quality of 
life. 
 
Alongside medication non-adherence, polypharmacy is highly prevalent among the elderly and 
patients with multi-morbidity. Polypharmacy refers to the use of inappropriate or not clinically 
needed medications, which is a problem in itself as well as a potential contributor to 
medication non-adherence. In industrialized countries such as Canada, it is estimated that the 
elderly and patients with multi-morbidity take three times as many prescription medications as 
other patients and that they consume 70% of all non-prescription medications (Gallagher, 
Barry, & O'Mahony, 2007). As the number of prescription and non-prescription medications 
increases, the risk for adverse drug events increases dramatically. 
 
Another contributing risk factor to drug-related complications is the physiology of aging. 
Specifically, there is significant inter-individual variation in medication responses that can be 
associated with age-related changes in pharmaco-kinetics and pharmaco-dynamics. Thus, 
careful individual medication dosing and monitoring is required. Finally, other high risk 
conditions such as having multiple health care providers (i.e., family physician and specialists) 

3 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
who prescribe medication(s) and having many care setting/context transitions also increase the 
threat of medication errors. 
 
Inappropriate use of medications in the elderly patient is of major concern to clinicians and 
public health authorities across Ontario, Canada and North America. 23% of patients have been 
found to experience an adverse event following discharge from the hospital. Adverse drug 
events are the most common type of adverse event, and found to be between 66% and 72% 
(Forster et al., 2004; Cornish et al., 2005).  Of these, 24% are preventable and due to 
medication error (Baker et al., 2004).  33–69% of medication-related hospital admissions in the 
United States are due to medication nonadherence (Osterberg & Blaschke, 2005). 
 
Optimal medication adherence has been linked to reduced hospitalizations and ED visits.  In an 
investigation of the impact of medication adherence on hospitalizations among patients taking 
medications related to diabetes, hypertension, hypercholesterolemia, and congestive heart 
failure, it was found that hospitalization rates were significantly lower among patients with high 
medication adherence(Sokol, McGuigan, Verbrugge, & Epstein, 2005). Likewise, adherent 
patients are less likely to experience an ED visit (Blanchard, Madden, Ross-Degnan, Gresenz, & 
Soumerai, 2013). 
 
Given the risks associate with poor adherence and the apparent contribution of good 
adherence to reducing hospitalizations and ED visits, interventions for promoting good 
adherence should be pursued.  To this end, a number of devices have been developed to 
promote medication adherence, though with limited success due to reliability, cost, etc.  The 
purpose of this study is to investigate the efficacy of the KARIE Automated Medication Delivery 
Device in enhancing medication adherence among a group of community-dwelling patients 
immediately following discharge from inpatient rehabilitation 
 
 
 

4 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
2 METHODS 
 
2.1 Design 
This study will utilize a multi-site randomized controlled trial design.  One week prior to 
discharge from inpatient rehab, consenting patients will be randomly assigned to receive 
medication self-management education only (SME) or medication self-management education 
+ KARIE (SME+K). 
 
2.2 Participants 
Study participants will include MSK, amputee, neuro rehabilitation and Geriatric Functional 
Enhancement Service (GFES) inpatients currently receiving care at West Park Healthcare Centre 
(Toronto) with a home transition plan following discharge.   Inclusion criteria will include: 
 need to manage medications independently at home; 
 stabilized on medication, as per pharmacist/physician discretion; and 
 mild-moderate cognitive/physical impairments, as per OT assessment 
 Montreal Cognitive Assessment (MoCA) score not less than 16 
 
It is anticipated that 20% of West Park patients will be eligible for SME and will consent to 
participation in the experimental trial. With 25 patients per unit and an average length of stay 
of 4-weeks on the MSK, amputee, neuro rehabilitation units, it is anticipated that a recruitment 
target of 75 experimental and 75 control subjects could be reached within a 10-month time 
frame (25 pts x 3 units x 20% x 10 months = 150 pts).  These 150 patients from West Park will 
be randomly assigned to the SME (n=75) or SME+K (n=75) group.  To meet this target an 
assumption of 80% compliance will be made.  Therefore, up to 94 participants per experimental 
arm will be recruited.  GFES length of stay is comparatively longer at roughly 12 weeks.  It is 
expected that fewer patients will be recruited from GFES, but will contribute toward meeting 
the recruitment target. 
 

5 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
One hundred fifty study participants will be recruited from the CapitalCare CHOICE programs 
(AB) which assist seniors to continue living independently and in their own home longer by 
managing all their health requirements. CapitalCare CHOICE clients attend one of three day 
centres, one to five days a week, and receive services which include ongoing medical, 
psychological, and social support. The total census for the CapitalCare CHOICE programs is 202 
clients and enrollment varies. Initial recruitment will significantly predict how quickly the target 
of 75 experimental and 75 control subjects can be reached. If after the initial recruitment 
period suggests challenges meeting the target within the study timeframe, recruitment will be 
opened up to the CapitalCare Adult Day Program, Laurier House, Post-Acute, Sub-Acute, and 
Restorative Care clients at CapitalCare’s other centres. The focus of these programs is to 
maintain client independence and autonomy while supporting personal care needs. 
 
2.3 Outcome Measures 
Primary objective: Usability and feasibility 
 Measures:  
o Self-Efficacy for Appropriate Medication Use Scale 
o Beliefs About Medication questionnaire (at baseline) 
o Satisfaction and acceptance questionnaire 
Secondary objective: medication adherence 
 Measures, Self-reporting:  
o Morisky Medication Adherence Scale 
o Medication Adherence Questionnaire 
o Brief Medication Questionnaire 
o 7-day recall 
 Measures, Objective:  
o Electronic data collected by the KARIE device. Adherence may be calculated as 
the number of dispensed doses/ the total number of prescribed doses during the 
prescription period *100 
 

6 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
3 Procedures 
 
3.1 Recruitment 
Potential West Park study participants will initially be identified by clinical staff referring to 
SME.  Apparently appropriate subjects will be informed of the study by a member of their care 
team and, if interested, identified as wishing to receive additional information about the study 
during their initial meeting with the SME OT.  The OT will briefly explain the nature of the study 
and request consent for the study research assistant (RA) to contact the patient to provide 
additional details of the study objective and procedures.  The RA will arrange to meet with 
patient expressing an interest in participating in the study to obtain written consent (see 
Appendix A) and conduct baseline measures.  The OT and pharmacist delivering the SMP will be 
blinded to group assignment.   
 
Potential CapitalCare study participants will be identified by the research team Occupational 
Therapist. The Occupational Therapist (OT) will share this information with the CapitalCare 
research assistant (RA) who will be in regular contact. The RA will acquire consent and collect 
baseline data from the client (see inclusion criteria and measures for definitions).  
 
The study RA, who will be blind to the assignment of the client to either intervention or control 
group, will approach the potential participant to explain the study, its purpose and aims to 
obtain informed consent for the study. As far as possible to maintain, the researcher will be 
unaware of the designation of the client to the Karie or control group. 
 
3.2 Subject Training 
 
3.2.1 Self-Medication Education Program 
West Park has a “Self-Medication Education Program” policy in place which seeks to establish 
independent medication SM capacity during the inpatient stay. Eligibility criteria for SME 
include a need to manage medications independently at home; stabilized on medication, as per 

7 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
pharmacist/physician discretion; and mild-moderate cognitive/physical impairments, as per OT 
assessment. To determine SME eligibility, an OT and pharmacist completes the 
Interprofessional Screening for Self Medication Readiness (Appendix B) to determine self-
management capacity. Eligible patients then receive training by an OT, followed by a 5-day self-
medication performance assessment (Appendix C) by an RN prior to discharge. Following 
discharge, these patients are often referred to receive 24 OT outpatient therapy sessions for 3-
months, on average.  
 
CapitalCare will adopt the West Park “Self-Medication Education Program” program and 
documentation for purposes of this study. To determine SME eligibility, an OT, Pharmacist, or 
RN will complete applicable portions of the Interprofessional Screening for Self Medication 
Readiness (Appendix B) to determine self-management capacity. Eligible clients then will 
receive training by an OT, followed by a 5-day self-medication performance assessment 
(Appendix C) by an RN. 
 
3.2.2 Orientation to KARIE 
Patients randomly assigned to receive SME+K will undergo Screening for Self Medication 
Readiness (Appendix A) to determine self-management capacity, will receive SME by an OT, 
followed by a 5-day self-medication performance assessment (Appendix B) by an RN prior to 
discharge, as described above (see “Self-Medication Program”).  In addition, this group will 
receive orientation to the KARIE Automated Medication Delivery Device.  Karie orientation will 
be integrated into SME and delivered by the study OT, Tiziana Bontempo. 
 
For purposes of this evaluation of the AceAge medication dispensing device, the SME and 
recruitment strategy will provide for: 1) standardized eligibility assessment, training, and 
performance evaluation of SM capacity for experimental and control subjects, 2) introduction 
to the AceAge device in the inpatient setting for experimental subjects, and 3) standardized 
medication adherence assessment during the 3-month outpatient follow-up period. 
 

8 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
3.3 Apparatus 
 
3.3.1 KARIE 
The KARIE device delivers medication with the right dose at the right time, but it also monitors 
medication adherence, sends reminder alarms and produces timely adherence and side effects 
reports for physician review. The KARIE device can receive customized messages from health 
care providers; for instance, the patient can be asked about side effect(s) and/or the efficiency 
of the prescribed medication. Capture of this critical information will improve the clinical 
team’s capacity to optimize the pharmacological treatment of chronic diseases, to assist in 
managing polypharmacy and to detect earlier medication related problems allowing them to 
intervene quickly to prevent the need for physician consultations, ER visits and/or 
hospitalizations. The KARIE device uses the multi-dose pouch packaging that pre-organizes 
drugs specific to the patient. Information on the package is read by KARIE to automatically 
schedule medication dispense and notification times. The device is simple with a single load 
action and a single button. In addition, it has communication capabilities such that if a patient 
misses a dose dispense, a notification is sent to a family member or caregiver who can then 
remind the patient. The device can also produce reports for physicians regarding medication 
adherence, side effects, chronic disease control, and non-prescription medication use, so they 
can better manage chronic disease care in patients with multi-morbidity. The KARIE device 
works as follows:  
1. Loading Medication:  
 Patient receives their medication pre-organized in a cartridge from their pharmacist;  
 The patient (or their informal caregiver) inserts the cartridge in the backside of the 
device; 
 The medication schedule is automatically loaded via 2D barcode; and 
 Device is ready to dispense. 
2. Daily Use:  
 Device notifies the patient when it is time for each medication through an audible 
noise and visual light;  

9 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 Patient presses button to dispense the specific medication for that point in time;  
 The device dispenses the correct medication and adherence data is collected 
 Patient takes the medication and adverse events in time can be recorded; and 
 Dose dispense times are logged by the device. 
3. Forgetting Medication:  
 Device notifies the patient when it is time for each medication through and audible 
noise and visual light; and 
 If patient does not take medication for 40 minutes or at customized times, a 
notification is sent.  
4. Patient-reported Outcomes:  
 Real-time data collection at time of dose dispense; 
 Customizable questions for study or medication relevancy; and 
 Create accurate, enriched datasets when combined with user log data. 
 
 
 
 

10 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
3.3.2 Medication Adherence Log 
Study participants in the SME and SME+K groups will be provided with a medication adherence 
log.  Participants will be asked to complete a log entry with every scheduled medication 
dispense time.  Participants will be asked to record the medications and the time they were 
taken.  If a medication was missed, participants will be asked to leave the entry blank for that 
particular time. 
 
3.4 Data Collection 
 
The study RA will contact each study participant to arrange a data collection session within 24-
48 hours prior to discharge.  Data collection will include those scales identified in Outcome 
Measures above.  Following discharge to the community, RAs will contact study participants via 
telephone on a bi-weekly basis to enquire about any missed medications.  During these 
telephone contacts the RA and study participant will review the medication adherence log for 
the previous 2 weeks. 
 
Data collection will be repeated at 3-months post-discharge.  The RA will contact the participant 
1-2 weeks prior to completion of the 3-month intervention period to schedule in in-home visit 
where post-intervention data collection will take place.  In addition, the RA will collect 
participant medication adherence log. 
 
 
4 ANALYSIS 
 
A 2x2 repeated measures analysis of variance will be conducted to test for significant between-
groups differences at baseline and post-intervention, as well as within-groups comparisons 
from baseline to post-intervention.  An intention-to-treat analysis using last-observation-
carried-forward will be used to account for subjects who do not complete the 3-month 
intervention. 

11 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
We will follow qualitative analysis methods established in healthcare research: simple content 
analysis of survey results and inductive thematic analysis of interview results. With regard to 
survey and interview data, we will also conduct descriptive statistics across intervention and 
control baseline measures to assess the variability within measures, and bivariate association 
between measures of adherence. Results will be interpreted cautiously rather than considered 
definitive. 
 
 
 
 
 

12 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
5. REFERENCES 
Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J. et al. (2004). The Canadian 
Adverse Events Study: the incidence of adverse events among hospital patients in Canada. 
CMAJ., 170, 1678-1686. 
Blanchard, J., Madden, J. M., Ross-Degnan, D., Gresenz, C. R., & Soumerai, S. B. (2013). The 
relationship between emergency department use and cost-related medication nonadherence 
among Medicare beneficiaries. Ann.Emerg.Med., 62, 475-485. 
Braun V, Clarke V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006; 3:77-101  
Conn, V., Taylor, S., & Miller, R. (1994). Cognitive impairment and medication adherence. 
J.Gerontol.Nurs., 20, 41-47. 
Cornish, P. L., Knowles, S. R., Marchesano, R., Tam, V., Shadowitz, S., Juurlink, D. N. et al. (2005). 
Unintended medication discrepancies at the time of hospital admission. Arch.Intern.Med., 165, 
424-429. 
Forster, A. J., Clark, H. D., Menard, A., Dupuis, N., Chernish, R., Chandok, N. et al. (2004). 
Advese events among medical patients after discharge from hospital. CMAJ., 170, 345-349. 
Gallagher, P., Barry, P., & O'Mahony, D. (2007). Inappropriate prescribing in the elderly. 
J.Clin.Pharm.Ther., 32, 113-121. 
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual. Health Res. 
2005; 15:1277 
 
Osterberg, L. & Blaschke, T. (2005). Adherence to medication. N.Engl.J.Med., 353, 487-497. 
Salive, M. E. (2013). Multimorbidity in older adults. Epidemiol.Rev., 35, 75-83. 
Sokol, M. C., McGuigan, K. A., Verbrugge, R. R., & Epstein, R. S. (2005). Impact of medication 
adherence on hospitalization risk and healthcare cost. Med.Care, 43, 521-530. 
Vermeire, E., Hearnshaw, H., Van, R. P., & Denekens, J. (2001). Patient adherence to treatment: 
three decades of research. A comprehensive review. J.Clin.Pharm.Ther., 26, 331-342.  h 
 
 

13 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
 
 
Informed Consent Form 
 
Title of Study: Next-generation medication dispenser to improve care 
at home for community-dwelling elderly 
 
Investigators:  
Tim Pauley 
 
 
 
 
 
 
Manager, Research and Evaluation 
 
 
West Park Healthcare Centre 
(416)243-3600 x2628 
 
Audrey Sand 
Manager, Evaluation and Knowledge Transfer  
CapitalCare Corporate Services  
(780)413-4702 
 
Purpose of Study: The purpose of the study is to determine whether 
clients using an in-home medication delivery device are more likely to 
take their medications as prescribed.  Previous research suggests that 
patients with good medication adherence are less likely to be require 
visits to the Emergency Department and are less likely to be 
hospitalized.  The KARIE Automated Medication Delivery Device will 
provide you with reminders when to take your medication and will 
dispense a small sealed envelope which will contain all the medications 
you require at a single time. 
 
Description of Study: If you choose to participate in this study, you will 
be assigned to participate in either a usual care group or the KARIE 
Automated Medication Delivery Device group (KARIE).  You will have an 
equal chance of being assigned to one group or the other.  If assigned 
APPENDIX A 

14 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
to the usual care group you will receive your medications in a standard 
blister pack by PharmaSave (West Park) or a Pharmacist (CapitalCare).  
If assigned to the KARIE group you will receive the KARIE device to use 
in your home as well as your regular medications which will be 
dispensed by the KARIE device. 
 
About KARIE:  The KARIE device is about the size of a large telephone 
and can be placed at a location you find convenient (e.g., kitchen table, 
bed side, etc.).  Your medication is pre-packaged as a strip of individual 
envelopes that is loaded into the back of the KARIE device.  When it is 
time for you to take your medications(s), KARIE will beep and light up.  
You will then press a button on the front of KARIE to receive a single 
medication envelope with all the medications you should take at that 
time.  KARIE will then reset itself for the next reminder time.   
 
 
 
Risks and Benefits: We do not foresee any risks associated with 
participation in this study.  You will receive all the medications you 
were prescribed at the point you were discharged from inpatient 
rehabilitation. 
 

15 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
Confidentiality:  The identity of all individuals who participate in this 
study will remain confidential.  Once data collection is complete, the 
information will be entered into an electronic database.  The original 
data collection sheets will be kept in a locked cabinet and subsequently 
destroyed after a period of six years.  Each participant will be assigned a 
unique identifier in the database for purposes of administering the 
data.  No names will appear in the database.  The findings will be 
analyzed and reported in a medical journal. 
 
This study has undergone ethical review and been granted approval by 
the Research Ethics Boards at West Park Healthcare Centre and 
CapitalCare. 
 
Informed Consent:  I have read and received a copy of the Patient 
Information sheet.  The research study has been explained to me and 
my questions have been answered to my satisfaction.  I understand 
that I may derive no personal benefit from participation in this study.  I 
know that I may ask now, or in the future, any questions I have about 
the study.  I have been assured that any records related to this study 
will be kept confidential.  The information obtained will be entered into 
an electronic database, a unique identifier will be assigned and the 
original questionnaire will be destroyed after a period of six years.  I 
understand that my participation is voluntary and that I am free to 
decide not to participate in this study or to withdraw from the study at 
any time.  I understand that my decision not to participate in this study 
will not jeopardise my relationship West Park Healthcare Centre or 
CapitalCare and will have no influence on my medical management.  At 
the end of the study a copy of the study results will be available to me 
upon request. I know if I have any concerns in the future about my 
rights as a research participant, I can call Dr. Ron Heslegrave, Chair, 
West Park Ethics Board at (416)217-3820 x2120 
 
 
 
 

16 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
_____________________ _____________________ _____________________ 
Name of Participant 
 
 
Signature 
Date 
_____________________ _____________________ _____________________ 
Person obtaining consent 
Signature 
Date 
 
 
 

17 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
 
 
Interprofessional Screening for Self Medication Readiness 
 
Eligibility criteria 
Yes 
No 
Initials 
Date 
Comments 
1. Does patient need ot manage meds 
independently upon d/c? 
 
 
 
 
 
2. Is patient expected to stay at least 5 
days? 
 
 
 
 
 
3. Does patient have aphasia? 
 
 
 
 
 
4. Does patient have dysphagia 
 
 
 
 
 
5. Admission date: _____ 
 
 
 
 
 
Cognitive status: 
Yes 
No 
Initials 
Date 
Comments 
1. Orientation to day of week 
 
 
 
 
 
2. Orientation to approximate time of 
day 
 
 
 
 
 
3. Ability to tell time form clock 
 
 
 
 
 
4. Ability to follow a calendar 
 
 
 
 
 
5. Admission MOCA score: _____ 
 
 
 
 
 
Physical status: 
Yes 
No 
Initials 
Date 
Comments 
1. Ability to open 
 
Dossette box compartments 
 
Medicine vials 
 
 
 
 
 
2. Ability to receive tablets from 
container 
 
 
 
 
 
3. Ability to ambulate or wheel self to 
nursing station independently (Level 2) 
 
 
 
 
 
Pharmacy/Nursing: 
Yes 
No 
Initials 
Date 
Comments 
Does patient consent to SMP? 
 
 
 
 
 
Ability to state home medication 
names/purpose? 
 
 
 
 
 
Previous non-compliance with meds? 
 
 
 
 
 
 
 
 
 
 
 
Evaluation: 
Yes 
No 
Initials 
Date 
Comments 
Eligible for SMP 
(all ‘yes’ except for shaded boxes; *at the 
discretion of the team) 
 
 
 
 
 
 
 
 
 
 
If not, name interventions: 
 
 
 
APPENDIX B 

18 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
 
 
SELF-MEDICATION PATIENT PERFORMANCE RECORD 
 LEVEL 1 (Minimum 48 hours) 
 LEVEL 2 (Minimum 72 hours) 
 Dosette 
 Vial/Bottle 
 Blister pack 
START A NEW PAGE WHEN: 
*progressing a patient to a new level* AND/OR *when changing medication containers (dosette vs. blister back vs. bottle)* 
 
Date 
yy/mm/dd 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Day no. 
 ___ 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 
Date 
yy/mm/dd 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Day no. 
 ___ 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 
 
 
 
 
 
 
 
APPENDIX C 
1 of 2 

19 | P a g e  
 
R e v i s e d  -  A p r i l  1 7 ,  2 0 1 8  
 
 
 
SELF-MEDICATION PATIENT PERFORMANCE RECORD 
 LEVEL 1 (Minimum 48 hours) 
 LEVEL 2 (Minimum 72 hours) 
 Dosette 
 Vial/Bottle 
 Blister pack 
 
Date 
yy/mm/dd 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Day no. 
 ___ 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 
Date 
yy/mm/dd 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Day no. 
 ___ 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 
Date 
yy/mm/dd 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Time 
Initials/Designation 
Day no. 
 ___ 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 Independent 
 Physical assistance 
 Verbal cueing re: 
compartment 
 (Level 2): Cueing to initiate 
 Other: _________ 
 
 
2 of 2