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Paper-based recording for clinical interventions Modified from Peterson, Tenni et al. 20092 Date:____________________________________________ Pharmacist:______________________________________________________ Consumer:_____________________________________________ Age:__________________________Sex:_________________________ Drug involved in DRP:______________________________________________________________________________________________ Other drug(s):_____________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Relevant medical conditions/allergies:________________________________________________________________________________ ________________________________________________________________________________________________________________ Notes:___________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Drug Related Problem (please circle) Drug Selection Recommendations (please circle) Difficulty using dosage form C5 Dose increase R1 C0 Dose decrease R2 Drug change R3 Duplication D1 Other compliance problem Drug interaction D2 Undertreated Wrong drug D3 Condition undertreated U1 Drug formulation change R4 Incorrect strength D4 Condition untreated U2 Drug brand change R5 Inappropriate dosage form D5 Preventive therapy required U3 Dose schedule/frequency change R6 Contraindications apparent D6 Other untreated indication problem U0 Prescription not dispensed R7 No indication apparent D7 Monitoring Other changes to therapy R8 Other drug selection problem D0 Laboratory monitoring M1 Refer to prescriber R9 Non-laboratory monitoring M2 Refer to hospital R10 M0 Refer for medication review R11 Other referral R12 Over or underdose Prescribed dose too high O1 Other monitoring problem Prescribed dose too low O2 Education Incorrect or unclear dosing instructions O3 Consumer requests drug information E1 Education or counselling session R13 Other dose problem O0 Consumer requests disease management advice E2 Written summary of medications R14 Other education or information problem E0 Dose administration aid R15 Other written information R16 N0 Monitoring: laboratory R17 Monitoring: non-laboratory R18 No recommendation R19 Compliance Under-use by consumer C1 Not classifiable Over-use by consumer C2 Not classifiable under another category Erratic use of medication C3 Toxicity or adverse reaction Intentional drug misuse C4 Toxicity, allergic reaction or ADR present Pharmaceutical Society of Australia T1
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