Attachment: Monitoring of Patient Response to Newly Assed Drug to The Formulary

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  • March 21, 2021
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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

DateInvestigation & lab. Test descriptionComment

E) Medication Prescription:

DoseFrequencyRouteStart dateStop dateComment

F) Patient Response:

1Improvement in signs / symptoms……………………………………………….
2Improvement in lab results……………………………………………….
3No response……………………………………………….
4Case deterioration……………………………………………….
5Unanticipated Adverse drug reaction……………………………………………….
6Allergic reactions……………………………………………….
7Others:……………………………………………….
……………………………………………..
Physician name, signature and stamp:
……………………………………………………….
Pharmacist received name, signature and stamp :

G) Drug Information Center comments and evaluation:

YESNOCOMMENTS
1Appropriateness for the approved indication(s)
2Enough investigations / Lab Test(s) appropriateness
3Appropriateness of the medication dosing according to the
indication
4Appropriateness of treatment duration
5Others:

Total number of cases studied:
Pharmacist name, signature and stamp:

P&T Committee Comments and Evaluation:

YESNO
1Drug is approved in the hospital formulary
2Drug is recalled
3Other recommendations:
………………………………………………………….
………………………………………………………….
………………………………………………………….
………………………………………………………….
………………………………………………………….

P&T committee chairperson:
Signature / stamp:
Date
:

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