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PSDIRF

This document is a patient specific drug information request worksheet. It collects information about the request including who made it, the patient, and the type of information needed. The actual drug information question is recorded, along with the required time frame for a response. Search planning and notes are documented. The final response is provided, and the outcome or what was done with the information is noted.

Uploaded by

Randy Fauske
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
189 views3 pages

PSDIRF

This document is a patient specific drug information request worksheet. It collects information about the request including who made it, the patient, and the type of information needed. The actual drug information question is recorded, along with the required time frame for a response. Search planning and notes are documented. The final response is provided, and the outcome or what was done with the information is noted.

Uploaded by

Randy Fauske
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Patient Specific Drug Information Request Worksheet

Date/Time Received______________ Person Receiving________________

How Received (i.e. Phone, Visit, etc.)_____________

Requestor/Source Information

Name: ________________ Preferred Method of Contact: Phone Pager Postal mail


Email

Affiliation: Address:

Phone #: ______________________

Pager #: ______________________

Fax #: _

Who Requested (Check One)

MD MD Student RN Pharmacist Patient

Physical/Respiratory Therapy Nutrition Support Secretary/Ward Clerk

Other_______________

Classification of Request

Adverse Drug Reaction Pharmacoeconomics Availability

Pharmacokinetics Compatability/Stability
Pregnancy/Lactation/Teratogenicity

Compounding/Formulation Poisoning/Toxicology Dosage/Schedule

Odd Drug Entities and OTCs Drug of Choice/Therapeutics/Pharmacology

Identification Method of Administration


Other_____________________

Patient Data

Patient Name:_ Patient ID: Room/Bed Number or Location:

Age Years Months Height ft in Setting: Inpatient Outpatient

Gender: Male Female Weight lb kg

Race: African-American Asian Caucasian Hispanic Other: _______________

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Diagnosis: _ Allergies/Intolerances _

Patient Data (Cont.)

Pertinent Medical History/Problem List:

Pertinent Medication History:

Pertinent Laboratory Values:

Miscellaneous Information:

The Request, Actual Drug Information Needed, and Time Frame for the Response

Original Question/Notes:

Clear Statement of Actual Drug Information Needed (Ultimate Question):

Time Frame Required for Response:

____________________________

Search Planning/Mapping

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___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

__

Record of Search/Notes

Clear Statement of Response

Clear Statement of Response

Q&A Verification (Did someone double check you? Who?):

Outcome

What was done with the information?

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