Outpatient Interventions
Date: eg 6/24/02
Patient Initials:
Provider Initials:
Site: Blackburn Cottage Corner Forest Manor Grassy Creek Midtown North Arlington PCC Main floor PCC 4th floor Westside
Medication Order Intervention: Not Applicable ADR avoided ADR detected Allergy Contraindication Dose change Dose verify Drug information Duplicate therapy Instruction change Interaction Rx-OTC Interaction Rx-herbal Interaction Rx-Rx Interaction Rx-food Interaction Rx-disease No drug indication Nonformulary to formulary conversion Refill too early Refill too late Untreated indication
Compliance Intervention: Not Applicable Device/Dosage Form Instruction Drug Regimen Review Follow-up phone call: RTS Follow-up phone call: Efficacy Follow-up phone call: MD follow-up Lifestyle Counseling Patient Counseling: Pt.-Pharm Patient Counseling: MD-Pharm Transportation (can't come to get Rx)
Other: Not Applicable Compounding Insurance Prior Authorization Special Order
Class of Drug: Rx Herbal OTC Vitamin
Drug:
Failure to Access Medication: Not Applicable None (received medication) Insurance Money Psycho/social issues Transportation
Outcome: Not Applicable Accepted Not accepted Left message Unable to contact
Cost Savings: Not Applicable Yes No Unable to determine
Enhanced Patient Care: Not Applicable Yes No Unable to determine
Time Factor for Intervention: 0-5 minutes 6-15 minutes 16-30 minutes 31-45 minutes 46 minutes to 1 hour Greater than 1 hour
Time Factor for Documentation: 0-5 minutes 6-15 minutes 16-30 minutes 31-45 minutes 46 minutes to 1 hour Greater than 1 hour
Explanation:
Student Initials:
Pharmacist Initials: