Appendices

APPENDIX 2–1: EXAMPLE OF DRUG INFORMATION CONSULT DOCUMENTATION FORM

APPENDIX 2–2: STANDARD QUESTIONS FOR OBTAINING BACKGROUND INFORMATION FROM REQUESTORS

Regardless of the type or classification of the question, the following information should be obtained:

1. The requestor’s name.

2. The requestor’s location and/or page number.

3. The requestor’s affiliation (institution or practice), if a health care professional.

4. The requestor’s frame of reference (i.e., title, profession/occupation, rank).

5. The resources the requestor has already consulted.

6. If the request is patient-specific or academic.

7. The patient’s diagnosis and other medications.

8. The urgency of the request (negotiate time of response).

The following questions should be asked when appropriate for specific requests^*.

Availability of Dosage Forms

1. What is the dosage form desired?

2. What administration routes are feasible with this patient?

3. Is this patient alert and oriented?

4. Does the patient have a water or sodium restriction?

5. What other special factors regarding drug administration should be considered?

Identification of Product

1. What is the generic or trade name of the product?

2. Who is the manufacturer? What country of origin?

3. What is the suspected use of this product?

4. Under what circumstances was this product found? Who found the product?

5. What is the dosage form, color markings, size, etc.?

6. What was your source of information? Was it reliable?

General Product Information

1. Why is there a particular concern for this product?

2. Is written patient information required?

3. What type of information do you need?

4. Is this for an inpatient, outpatient, or private patient?

Foreign Drug Identification

1. What are the drug’s generic name, trade, manufacturer, and/or country of origin?

2. What is the dosage form, markings, color, strength, or size?

3. What is the suspected use of the drug? How often is the patient taking it? What is the patient’s response to the drug? Is the patient male or female?

4. If the medication was found, what were the circumstances/conditions at the time of discovery?

5. Is the patient just visiting, or are they planning on staying?

Investigational Drug Information

1. Why do you need this information? Is the patient in need of the drug or currently enrolled in a protocol?

2. If a drug is to be identified, what is the dosage form, markings, color, strength, or size of the product?

3. Why was the patient receiving the drug? What is the response when the patient was on the drug? What are the patient’s pathological conditions?

4. If a drug is desired what approved or accepted therapies have been tried? Was therapy maximized before discontinued?

Method and Rate of Administration

1. What dosage form or preparation is being used (if multiple salts available)?

2. What is the dose ...