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?