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Never paste real patient identifiers into AI tools. Strip all names, dates of birth, MRNs, insurance numbers, and any other PHI before entering data. Use generic labels like "Patient A" or age ranges instead of exact ages. HIPAA compliance is your responsibility regardless of the tool you use.
Use the Strand classification explicitly. When asking the AI to identify drug-related problems, naming the Strand categories (unnecessary therapy, needs additional therapy, wrong drug, dose too low, dose too high, ADR, nonadherence) in your prompt produces much more systematic and complete output than vague requests like "find medication problems."
Include lab values and vitals whenever possible. MTM documentation is strongest when clinical data supports every recommendation. The more objective data you provide in the prompt, the more specific and defensible the AI-generated documentation will be.
Cross-reference AI output against your clinical references. AI may suggest dose adjustments or therapeutic recommendations that are outdated or incorrect for your specific patient context. Always validate recommendations against Lexicomp, Clinical Pharmacology, or current clinical guidelines before finalizing documentation.
Map every medication to a diagnosis. Including diagnosis-to-drug mapping in your prompt forces both you and the AI to account for every therapy. This is the single most effective way to catch unnecessary medications and identify untreated conditions during an MTM review.
5 Claude Prompts for Drug Information Queries
5 Claude Prompts for Prior Authorization
Claude CoWork for Pharmacists
ClaudePharmacistBeginnerPrompt Pack
5 Claude Prompts for MTM Documentation — Pharmacists
Ready-to-use Claude prompts for medication therapy management notes, comprehensive medication reviews, and clinical documentation.
Why Use AI for MTM Documentation?
Medication therapy management is one of the highest-value clinical services pharmacists provide, but the documentation burden can be significant. A single comprehensive medication review involves assessing every active medication for appropriateness, identifying drug-related problems, creating an action plan, and documenting it all in a format that satisfies CMS requirements and supports billing. When you are trying to complete multiple MTM encounters in a day alongside dispensing duties, documentation quality often suffers — and incomplete documentation means lost revenue and gaps in the clinical record.
AI tools like Claude can help you structure and draft your MTM documentation faster without sacrificing completeness. By feeding in de-identified medication lists, lab values, and clinical observations, you can generate well-organized SOAP notes, CMR summaries, and follow-up plans that hit every required documentation element. The AI handles the narrative structure and formatting; you contribute the clinical assessment and decision-making that only a pharmacist can provide.
These prompts are built around standard MTM documentation frameworks including the pharmacist patient care process (PPCP) and CMS-compliant CMR formats. As with all clinical AI use, remove all patient identifiers before using these prompts, and verify every clinical recommendation in the output against your professional judgment and current references.
Prompt 1: Comprehensive Medication Review (CMR) Documentation
Generate a complete CMR summary document from a patient's medication list and clinical data.
You are a clinical pharmacist completing a Comprehensive Medication
Review. The patient has the following active medications:
[LIST ALL MEDICATIONS WITH DOSES AND FREQUENCIES]. Their diagnoses
include: [LIST CONDITIONS WITH ICD-10 CODES IF AVAILABLE]. Relevant
lab values: [LIST KEY LABS, e.g., "A1C 8.4%, LDL 142 mg/dL, SCr
1.3 mg/dL, BP average 148/92"]. Generate a CMR document that
includes: a medication list with indication mapping (each drug
matched to a condition), identified drug-related problems (using
categories: unnecessary therapy, needs additional therapy, wrong
drug, dose too low, dose too high, adverse drug reaction,
nonadherence), a Personal Medication Record summary, and a
Medication Action Plan with prioritized recommendations. Format
per CMS MTM documentation standards.Example Output:
Comprehensive Medication Review — Patient A
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Medication-Indication Mapping: Metformin 1000 mg BID — Type 2 Diabetes (E11.65); Lisinopril 20 mg daily — Hypertension (I10) / Diabetic nephropathy; Amlodipine 10 mg daily — Hypertension (I10); Atorvastatin 20 mg daily — Hyperlipidemia (E78.5); Omeprazole 20 mg daily — no active indication documented.
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Drug-Related Problems Identified: (1) Unnecessary therapy: Omeprazole 20 mg daily — no documented GI diagnosis, patient reports no reflux symptoms, on therapy over 14 months. Recommend taper and discontinuation. (2) Dose too low: Atorvastatin 20 mg in a diabetic patient with LDL 142 mg/dL. Guidelines recommend high-intensity statin therapy. Recommend increasing to atorvastatin 40-80 mg daily. (3) Needs additional therapy: A1C 8.4% on metformin monotherapy suggests need for second-line agent. Consider SGLT2 inhibitor given renal and cardiovascular benefits.
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Medication Action Plan: Priority 1 — Contact prescriber to intensify statin and discuss addition of SGLT2 inhibitor. Priority 2 — Initiate omeprazole taper with patient education on rebound acid hypersecretion. Follow-up scheduled in 30 days.
Why it works: Mapping every medication to a diagnosis forces a systematic therapeutic review and ensures the documentation clearly justifies each therapy — a key element for CMS compliance.
Prompt 2: SOAP Note for Clinical Encounter
Draft a structured SOAP note for a pharmacist clinical intervention or MTM session.
Write a pharmacist SOAP note for the following clinical encounter:
Subjective: Patient reports [SYMPTOMS OR CONCERNS, e.g., "dizziness
when standing up, especially in the morning; has missed doses of
amlodipine 2-3 times per week"]. Objective: [CLINICAL DATA, e.g.,
"BP sitting 138/86, BP standing 112/74; current medications:
amlodipine 10 mg daily, lisinopril 20 mg daily, metformin 1000 mg
BID; recent labs: K+ 4.1, SCr 1.1, A1C 7.8%"]. Write a complete
Assessment section identifying the drug-related problems, and a
Plan section with specific, actionable pharmacist recommendations
including any prescriber communication needed. Use standard clinical
documentation language.Example Output:
S: Patient reports dizziness when standing, particularly in the morning. States she has been missing amlodipine doses 2-3 times per week due to forgetting. Denies chest pain, headache, or visual changes. Reports adequate fluid intake.
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O: BP sitting 138/86 mmHg, BP standing 112/74 mmHg (orthostatic drop of 26/12 mmHg). Current medications: amlodipine 10 mg daily, lisinopril 20 mg daily, metformin 1000 mg BID. Labs: K+ 4.1 mEq/L, SCr 1.1 mg/dL (eGFR 68 mL/min), A1C 7.8%.
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A: (1) Orthostatic hypotension likely related to combined antihypertensive therapy with amlodipine 10 mg and lisinopril 20 mg. Symptomatic orthostatic drop exceeds 20 mmHg systolic threshold. (2) Nonadherence to amlodipine — missed doses 2-3 times weekly contributing to variable blood pressure control. (3) Diabetes not at individualized A1C goal; current regimen may need optimization.
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P: (1) Recommend prescriber reduce amlodipine from 10 mg to 5 mg daily to address orthostatic symptoms; reassess BP in 2 weeks. (2) Transition amlodipine to evening dosing and provide pill organizer to improve adherence. (3) Educate patient on slow positional changes. (4) Fax clinical recommendation to Dr. Martinez regarding dose adjustment. Follow up by phone in 14 days to reassess symptoms and adherence.
Prompt 3: Drug-Related Problem Identification
Systematically screen a medication list for drug-related problems and generate a prioritized problem list.
Review the following medication list for a [AGE]-year-old patient
with [LIST DIAGNOSES]: [LIST ALL MEDICATIONS WITH DOSES AND
FREQUENCIES]. Also consider these clinical parameters: [LIST RELEVANT
LABS, VITALS, AND PATIENT-REPORTED ISSUES]. Identify all potential
drug-related problems using the Strand classification: unnecessary
drug therapy, needs additional drug therapy, wrong drug, dosage too
low, dosage too high, adverse drug reaction, and nonadherence.
For each problem identified, provide: the specific drug(s) involved,
the clinical rationale for why it is a problem, the severity rating
(high / moderate / low), and a recommended intervention. Prioritize
the list from most clinically urgent to least.Example Output:
Drug-Related Problem List — Patient A, 72-year-old with Type 2 Diabetes, Hypertension, Atrial Fibrillation, Osteoarthritis
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Problem 1 (High Severity) — Adverse Drug Reaction: Warfarin 5 mg daily + Naproxen 500 mg BID. Concurrent use of an anticoagulant with an NSAID significantly increases GI bleeding risk. INR last recorded at 3.4, above therapeutic range. Intervention: Recommend discontinuing naproxen immediately. Suggest acetaminophen 650 mg TID as first-line alternative for osteoarthritis pain. Notify prescriber urgently and recheck INR within 3 days.
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Problem 2 (High Severity) — Dosage Too Low: Metformin 500 mg daily for Type 2 Diabetes with A1C 9.1%. Current dose is subtherapeutic. Intervention: Recommend titrating to metformin 1000 mg BID as tolerated, with renal function monitoring given eGFR 52 mL/min.
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Problem 3 (Moderate Severity) — Needs Additional Therapy: Patient with diabetes and hypertension but no ACE inhibitor or ARB on profile despite evidence of microalbuminuria. Intervention: Recommend initiating lisinopril 10 mg daily for renal protection. Coordinate with prescriber.
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Problem 4 (Low Severity) — Nonadherence: Patient reports skipping evening metoprolol doses due to fatigue. Intervention: Counsel on importance of rate control in atrial fibrillation; explore extended-release formulation for once-daily dosing.
Prompt 4: MTM Follow-Up Plan
Create a structured follow-up plan after an initial MTM encounter to track interventions and outcomes.
Based on the following MTM interventions made during a CMR session,
create a structured 30-day follow-up plan:
Interventions completed:
1. [INTERVENTION, e.g., "Recommended prescriber discontinue
omeprazole — no active indication, patient on therapy >12 months"]
2. [INTERVENTION, e.g., "Identified need for statin therapy — patient
with diabetes, LDL 148, no current lipid-lowering agent"]
3. [INTERVENTION, e.g., "Counseled patient on metformin timing with
meals to reduce GI side effects"]
4. [INTERVENTION, e.g., "Identified duplicate calcium channel blocker
therapy — amlodipine 5 mg and nifedipine ER 30 mg"]
For each intervention, generate: the specific follow-up action needed,
the target date, measurable outcome criteria (e.g., "LDL <100 mg/dL
at next lab draw"), and documentation language for the follow-up note.
Format as a table if possible.Example Output:
| Intervention | Follow-Up Action | Target Date | Outcome Criteria | Follow-Up Documentation |
|---|---|---|---|---|
| Recommended discontinuation of omeprazole (no active indication, >12 months of therapy) | Contact prescriber to confirm order was discontinued; call patient to assess for rebound symptoms during taper | Day 14 | Omeprazole successfully discontinued; patient reports no reflux recurrence | "Follow-up: Prescriber accepted recommendation and discontinued omeprazole on [date]. Patient reports mild heartburn during first week of taper, now resolved. No further PPI therapy indicated at this time." |
| Identified need for statin therapy (diabetic patient, LDL 148 mg/dL) | Verify new statin prescription was sent to pharmacy; confirm patient picked up and started medication | Day 10 | Statin prescription on file and first fill dispensed; LDL target <100 mg/dL at next lab draw | "Follow-up: Atorvastatin 40 mg daily initiated on [date]. Patient counseled on administration, muscle pain monitoring, and adherence. Repeat lipid panel ordered for 8-week follow-up." |
| Counseled patient on metformin timing with meals | Phone call to assess GI tolerance and adherence to mealtime dosing | Day 14 | Patient reports reduced nausea and bloating; taking metformin consistently with meals | "Follow-up: Patient confirms improved GI tolerance since adjusting metformin to mealtime dosing. No missed doses in the past week. Will continue current regimen." |
| Identified duplicate CCB therapy (amlodipine 5 mg + nifedipine ER 30 mg) | Confirm prescriber discontinued one agent; monitor BP at next visit | Day 7 | One CCB discontinued; BP remains <140/90 mmHg on monotherapy | "Follow-up: Prescriber discontinued nifedipine ER on [date]. Patient's BP at pharmacy check today 134/82 mmHg on amlodipine 5 mg alone. No adverse effects reported." |
Prompt 5: Medication Reconciliation Summary
Generate a structured medication reconciliation document comparing multiple medication sources.
Perform a medication reconciliation analysis comparing these three
medication sources for the same patient:
Hospital discharge list: [LIST MEDICATIONS]
Patient's home medication bottles: [LIST MEDICATIONS]
PBM/pharmacy fill history: [LIST MEDICATIONS WITH LAST FILL DATES]
Identify all discrepancies between the three sources, categorize
each discrepancy (new medication added, medication discontinued,
dose changed, duplicate therapy, missing from one source), and flag
any discrepancies that represent a safety risk. For each discrepancy,
recommend a resolution action (confirm with prescriber, clarify with
patient, update profile, etc.). Present the reconciliation in a
three-column comparison table followed by a narrative summary of
critical findings.Example Output:
Medication Reconciliation — Patient A (Post-Discharge)
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| Medication | Hospital Discharge List | Home Bottles | Pharmacy Fill History | Discrepancy |
|---|---|---|---|---|
| Metoprolol succinate 50 mg daily | Present | Present (25 mg tablets found) | Last fill: metoprolol succinate 25 mg, filled 45 days ago | Dose changed — Discharge list shows 50 mg but home supply and fill history show 25 mg. New dose likely initiated at discharge. |
| Apixaban 5 mg BID | Present | Not found | No fill history | New medication — Started during hospitalization for new atrial fibrillation diagnosis. No home supply yet. SAFETY FLAG: Patient has no supply of anticoagulant post-discharge. |
| Omeprazole 40 mg daily | Not listed | Present (40 mg capsules) | Last fill: 22 days ago | Potentially discontinued — Absent from discharge list but patient still has active supply at home. Clarify whether intentionally discontinued during admission. |
| Clopidogrel 75 mg daily | Not listed | Present (75 mg tablets, expired) | Last fill: 8 months ago | Likely discontinued — Not on discharge list, expired supply at home, no recent fills. Confirm discontinuation with prescriber. |
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Critical Findings: Highest-priority action is ensuring the patient fills the new apixaban prescription immediately, as there is currently no anticoagulant supply at home despite a new atrial fibrillation diagnosis. The metoprolol dose change from 25 mg to 50 mg must be confirmed with the patient and updated in the pharmacy system to prevent dispensing the old dose on the next refill. Prescriber should be contacted to clarify omeprazole status.