This form will be used when the user; either a physician or a pharmacist is requesting a specific drug to be added to the pharmacy formulary. The drug in this case is to be monitored for a period of at least three months to perform a proper evaluation of both efficacy, patient response rate and cost. The form is part of the main policy “Pharmacy formulary system policy” and this attachment serves as an example of the form, make sure to change the header and footer to better suit your organization design style, and add the proper dates of creation, modification and due to review date.
| HOSPITAL NAME – PHARMACY AND THERAPEUTICS COMMITTEE MONITORING OF PATIENT RESPONSE TO NEWLY ADDED DRUG TO THE FORMULARY DURING ITS INTRODUCTORY PERIOD (3 MONTHS) |
|---|
| Medication name: |
| Monitoring period: from __ /__ /____ to __ /__ /____ |
| A) Medication description: Generic name: Brand name: clinical pharmacological class: Dosage form / strength: |
B) Patient information:
| Name: | Age: | ||
| File number: | Gender | ||
| DOA/visit: | Height: | ||
| Ward: | Weight: | ||
| Encounter number: | Allergies: |
C) Diagnosis /Approved indication for the prescribed drug
| 1 | ||
| 2 | ||
| 3 | ||
| 4 |
D) Investigations / Lab test
| Date | Investigation & lab. Test description | Comment |
|---|---|---|
E) Medication Prescription:
| Dose | Frequency | Route | Start date | Stop date | Comment |
|---|---|---|---|---|---|
F) Patient Response:
| 1 | Improvement in signs / symptoms | ………………………………………………. | |
| 2 | Improvement in lab results | ………………………………………………. | |
| 3 | No response | ………………………………………………. | |
| 4 | Case deterioration | ………………………………………………. | |
| 5 | Unanticipated Adverse drug reaction | ………………………………………………. | |
| 6 | Allergic reactions | ………………………………………………. | |
| 7 | Others: | ………………………………………………. |
| …………………………………………….. Physician name, signature and stamp: | ………………………………………………………. Pharmacist received name, signature and stamp : |
G) Drug Information Center comments and evaluation:
| YES | NO | COMMENTS | ||
|---|---|---|---|---|
| 1 | Appropriateness for the approved indication(s) | |||
| 2 | Enough investigations / Lab Test(s) appropriateness | |||
| 3 | Appropriateness of the medication dosing according to the indication | |||
| 4 | Appropriateness of treatment duration | |||
| 5 | Others: |
Total number of cases studied:
Pharmacist name, signature and stamp:
P&T Committee Comments and Evaluation:
| YES | NO | ||
|---|---|---|---|
| 1 | Drug is approved in the hospital formulary | ||
| 2 | Drug is recalled | ||
| 3 | Other recommendations: …………………………………………………………. …………………………………………………………. …………………………………………………………. …………………………………………………………. …………………………………………………………. |
P&T committee chairperson:
Signature / stamp:
Date:
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