CLINICAL INTERVENTIONS FORM
Home
Pharmacist's Name:
Phil DeAngelis
Linda Fonda
Mark Hohenwarter
Dave Krempasky
Zonara Qureshi
Ray Sinotte
Virginia Tucciarone
Date:
Problem:
ADVERSE DRUG REACTION
CREATININE CLEARANCE ESTIMATED
CIPRO-IV, PO RECOMMENDED
LEVAQUIN-IV, PO RECOMMENDED
ZITHROMAX-IV, PO RECOMMENDED
ORDER NEEDS CLARIFICATION!
COUMADIN DOSE CHK VS PT
COUMADIN COUNSELING COMPLETE
CULTURE/SENSITIVITY REVIEWED
DRUG ALLERGY
DOSE CALCULATED BY RPH
DRUG-DISEASE INTERAC/CONTRAIND
DRUG-DRUG INTERAC/INCOMPAT
DIG LEVEL CHECKED
LAB LEVELS MONITORED!
DRUG LEVELS HI/NOT MONITORED!
LITHIUM LEVELS CHECKED
DRUG TAKEN OFF MARKET
MEDICATION ORDER ERROR
NON-FORMULARY DRUG
PAIN CONSULT REQUESTED
PREVENTED MEDICATION ERROR
TIME SPENT/SOLVING PYXIS PBLEM
RESTRICTED DRUG
THERAPEUTIC SUBSTITUTION
THEOPHYLLINE LEVELS CHECKED
TORADOL DOSE REVIEWED/CHANGED
TCU PATIENT CARE CONFERENCE
Signif:
HIGH
MODERATE
MINIMAL
Action:
CLARIFIED WITH RN!
DRUG INFO TO MED OR NSG STAFF
COUNSELLED PATIENT'S FAMILY
LABORATORY CONSULTED
CONTACTED ATTENDING PHYSICIAN
CONTACTED CONSULTING PHYSICIAN
COUNSELLED PATIENT
WORKED ON SOLVING PYXIS
CONTACTED NURSE
REVIEWED BY RPH
Intrv:
CHART CHECKED BY RPH
CHECKED DOSING VS CREAT.CL.
CULTURE REVIEWED-ORDER CHANGED
CULTURE REVIEWED NO CHANGE
DRUG INFO DISPENSED
MD NOTIFIED
ORDER CLARIFIED AND CHANGED
ORDER CLARIFIED
ORDER CONTINUED
TORADOL DOSE REVIEWED
Accept:
DOES NOT APPLY!
PENDING-MD NOTIFIED
RECOMMENDATION ACCEPTED
RECOMMENDATION DECLINED
RECOMM DECLINED & JUSTIFIED
Outcome:
AVOIDED ALLERGIC REACTION
AVOIDED EXCESSIVE COST
AVOIDED ADR/TOXICITY
CIPRO-SWITCH SAVINGS OF $41/D
IMPROVED APPROPRIATENESS
IMPROVED EFFECTIVENESS
INTERRUPTION OF RX AVOIDED!
MD ALERTED- NO CHANGE
ORDER DISCONTINUED BY MD
PREVENTED MED ERROR
SAFETY GUARANTEED FOR PATIENT
Dr.Name
Comments:
Click to
this page
Top
