guidelines for inpatient pharmacy practicejknj.moh.gov.my/farmasi/garispanduan/[2010] guidelines...

Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia 1

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2 Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia

MINISTRY OF HEALTH MALAYSIA

First Print, 2010Pharmaceutical Services Division,Ministry of Health, Malaysia.

ALL RIGHTS RESERVED

No part of this publication may be reproduced, storedor transmitted in any form or by any means whetherelectronic, mechanical, photocopying, tape record-ing or others without written permission from theSenior Director of Pharmaceutical Services, Minis-try of Health, Malaysia.

Perpustakaan Negara Malaysia

Guidelines for Inpatient Pharmacy Practice, Ministryof Health Malaysia.ISBN 978-967-5570-12-4


Pharmacy Practice and Development Division has been evolving and this is evidencedthrough years of excellence in performance. Primarily focussed on patient safety, weare responsible for the optimisation of drug therapy and prevention of medication errors.

Throughout the expansion of services, Pharmacy Practice and DevelopmentDivision has introduced standardisation of procedures towards assisting propermanagement of Drug Distribution and Ward Pharmacy activities. This Guidelines forInpatient Pharmacy Practice will serve as a tool for all to work conscientiously for thebenefit of patients.

This guideline focuses on good management of drug distribution describes workflows of the Inpatient Pharmacy processes and explanation of the necessarydocuments involved. It is hoped that the guidelines are able to steer goodmanagement practice in conducive environments towards fulfilment of customers'needs.

I would like to convey my gratitude to the Clinical & Technical Pharmacy WorkingCommittee in the success of producing this guideline. Also, a special thanks to allparties that contributed during all stages of development and publication of thisguideline.

Thank you

Hasnah binti IsmailDirector,Pharmacy Practice and Development Division,Ministry of Health Malaysia.

PREFACE

DirectorPharmacy Practice and Development DivisionMinistry Of Health Malaysia


Preface 3

Table of Contents 4

Editorial Board 5

1.0 Inpatient Pharmacy Services 9

2.0 Drug Distribution Activities 102.1 Unit Dose System 102.2 Floor Stock / Emergency Trolley Medications 162.3 After Office Hours Supply 172.4 Supply of Psychotropic Medicines 172.5 Supplies for Discharged Patients 172.6 Handling Referral Letter (Second Copy) and

Supply of Medications for Patients being referredto Health Facilities 18

2.7 Ward / Unit Medication Inspection 19

3.0 Ward Pharmacy Activities 213.1 Medication History Taking 223.2 Case Clerking 223.3 Pharmacotherapy Rounds 233.4 Medication Review 253.5 Medication Reconciliation 263.6 Medication Counselling 243.7 Discharge Planning 28

4.0 Other Activities4.1 Clinical Pharmacokinetic Service 304.2 Drug Information Service 314.3 Adverse Drug Reaction Monitoring and Reporting 314.4 Medication Error Reporting 324.5 Product Complaint Reporting 334.6 Processing Request for Non-Formulary Medications 33

5.0 Documentations 34

6.0 Reference 40

7.0 Appendices 41

8.0 Glossary 67

Table of Contents Page


Advisors

Eisah A RahmanSenior Director of Pharmaceutical Services,Ministry of Health Malaysia

Hasnah IsmailDirector of Pharmacy Practice and DevelopmentPharmaceutical Services Divison, MOH

Editors

Abida Haq Syed M. HaqDeputy DirectorPharmaceutical Services Division, MOH

Ainul Salhani Abdul RahmanPrincipal Assistant DirectorPharmaceutical Services Division, MOH

Rabi'ah MamatPrincipal Assistant DirectorPharmaceutical Services Division, MOH

Phuar Hsiao LingSenior Assistant DirectorPharmaceutical Services Division, MOH

Editorial Board


GUIDELINES FORGUIDELINES FORGUIDELINES FORGUIDELINES FORGUIDELINES FOR

INPINPINPINPINPAAAAATIENT PHARMATIENT PHARMATIENT PHARMATIENT PHARMATIENT PHARMACCCCCYYYYY

PRAPRAPRAPRAPRACTICECTICECTICECTICECTICE


Pharmaceutical care is an area in the health care system which has yet to be fullydeveloped in Malaysia although it has generated tremendous impact worldwide. Sinceits inception in the 1990's, Malaysian pharmacists have embarked on a bold anddramatic leap forward to embrace its philosophy in all areas of pharmaceutical careservices. Much effort has been put into exploring ways in which to instil and initiatepharmaceutical care activities in both the outpatient and inpatient settings.

Ward pharmacy activities encompass issues on all aspects of pharmacotherapy. Duringward rounds, input pertaining to appropriateness of therapy, counselling of patients onmedication therapy and the monitoring of unwanted side effects are the majorservices provided. Often time, the input given is not documented. Thus, a mechanismto document these activities is crucial and urgently required.

The pharmaceutical needs of a patient refer to his or her requirements for pharmaceuticalproducts or services. Pharmaceutical needs may be identified by any member of thehealth care team or by the patient him/herself. Once a targeted patient group has beenassigned to the responsibility of a clinical pharmacist, a function of the delivery of theservice is to prioritise the individual patient in the group according to his/her potentialpharmaceutical care issues (PCI).

It is important to document the outcomes of the pharmaceutical care intervention forthe purpose of individual patient records as well as information for the management.

Information on issues such as drug availability, dosage form, procurement andstorage should be managed in liaison with colleagues in other units. Pharmacistsrequire both knowledge and clinical experience to be a useful member of the healthcare team. Therefore the clinical pharmacist serves as a liaison person betweenpatients, doctors, nurses and fellow pharmacists.

INPATIENT PHARMACY SERVICES1.0

I n p a t i e n t P h a r m a c y S e r v i c e s 1.0

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Objectives

The pharmacy department should implement a distribution system that meets thefollowing objectives:

i. To dispense prescribed drugs to patients in wards in a timely and efficientmanner

ii. To avoid occurence of medication error

iii. To minimise drug wastage

iv. To minimise opportunities for drug diversion

v. To maintain information on drug utilization and rational drug use

vi. To identify unusual patterns of drug usage

Drug Distribution Method

Currently, three types of drug distribution systems are being practiced i.e. thetraditional system, unit-of-use system and unit dose system. The unit dose system(UDS) should be encouraged due to its many advantages. The UDS involves dispensingof drugs to individual patients on a daily basis and for 24 hour duration only. The unit-of-use system (UoU) is similar to UDS in many ways except to the duration of supply.Drug distribution system may be centralised or decentralised depending on locationand facility itself.

Other activities include:i. Floor Stock / Emergency Trolleys Medication

ii. After Office Hours Supply

iii. Supply For Psychotropic Medicines

iv. Supplies For Discharged Patients

v. Ward / Unit Inspection

2.1 UNIT DOSE SYSTEM

All medications dispensed to patients in the wards should be kept in individually labelleddrawers or trays in the medication trolleys for patients. The amount of medicationdispensed should be according to the dosage regimen and placed in compartmentswithin the patient drawers. The medication trolley must be lockable and the keys keptby a registered nurse in the specific ward and another by an authorised pharmacystaff.

DRUG DISTRIBUTION ACTIVITIES2.0

2.0 D r u g D i s t r i b u t i o n A c t i v i t i e s

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2.1.1 Handling of Medication Trolley

1. The medication trolley should be sent to the pharmacy by the nurseon duty for the supply of new prescriptions and daily refilling of currentprescriptions after dose administration times, usually at 8.00am.

2. The trolley has to be collected by ward staff before the next doseadministration time at 12.00 noon.

2.1.2 Medication Order

1. The medication order for ward patients must be completed in theself-carbonised Medication Chart and signed by the prescriberaccording to the categories set by the Ministry of Health MalaysiaDrug Formulary (FUKKM).

2. Each prescription must be written with the generic name, completewith dose in mg, ml or IU; administration route such as SC, IM, IV,PO, LA or others; administration frequency such as DAILY, BD, TDS,QID etc; treatment duration such as 5/7, 1/52 or 2/52; starting date;prescriber's signature; patient name and ward/bed number.

3. All prescriptions of medications for A, A/KK or A* categories must bestamped and countersigned by the relevant specialist. Controlledmedicines must be attached with application forms according to thepractice in individual institutions.

4. All original prescriptions (white) from the Medication Chart shouldbe separated from the carbonised copy (yellow) (Appendix 1). Thecarbonised copy should be retained in the ward.

5. A new medication order (prescription) must be made in the followingsituations:a) Newly-admitted patientsb) Patients transferred in from other wardsc) Patients who have just undergone an operation or special

proceduresd) Expired prescriptions but treatment needs to be continued

6. For patients who have just been admitted into the ward, theprescription has to be sent with the patient's Cumulative MedicationRecord (Appendix 2).

7. For patients currently in the ward, any addition of medications mustbe made through a prescription. Any changes in dose, dosage form,frequency or treatment duration warrants a new prescription attachedwith an Advice Note (Appendix 3).

D r u g D i s t r i b u t i o n A c t i v i t i e s 2.0

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8. The completed original prescription must be separated from theself-carbonised copy, collected and sent to the pharmacy.

9. The nurse on duty is responsible for sending prescriptions for allpatients in the ward to the pharmacy. Under certain circumstances,the nurse can direct the Penolong Perawatan Kesihatan (PPK) tosend the prescriptions to the pharmacy.

2.1.3 Receiving the Prescription

1. All prescriptions received must be checked by the Pharmacist/Pharmacy Assistant to ensure that they are complete.

2. Screening of all prescriptions should be done by the pharmacist toensure the following:a) Authenticity of prescription/prescriberb) Adherence to FUKKMc) Suitability of dosing regimend) Drug interactionse) Polypharmacyf) Correct medication administration method and frequencyg) Others

3. For any other interventions, the Pharmacist/ Pharmacy Assistantshould either contact the medical officer concerned for clarificationor issue an Intervention Note (Appendix 4).

4. Any changes made to the prescription can only be made with theprior consent of the prescriber concerned and recorded into the'Notes' column of the CMR. If the countersignature for Category Amedications has not been obtained, the prescription should becopied into the CMR and the medication supplied first while waitingfor the countersignature. The Intervention Note that states thenecessity for the specialist's signature should be sent to the wardwith the prescription. After it is signed, the prescription will bereturned to the pharmacy to be pasted on the CMR.


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5. All new prescriptions which have been screened should be pastedon the patient's CMR and the expiry date of the prescription recordedin the amount column.

For example:

6. To discontinue a medication, the prescription at the CMR must bestamped with "UBAT DIBERHENTIKAN". At the Medication Chart(yellow copy) in the ward, the prescriber/pharmacist/nurse can recordthe discontinuation of the medication in the yellow copy.

7. To withhold medication, it must be recorded as "WH" in the CMR atthe amount column. The same should be done for the MedicationChart in the ward, which should be done by the doctor/ pharmacist/nurse.

8. Changes in medication dose or administration frequency need to bestamped with "RUJUK PRESKRIPSI BARU".

2.1.4 Filling of Prescriptions

1. All medications supplied to the ward must be in ready-to-use form ina container meant for administration of one dose and not exceedingthe requirements for 24 hours.

2. Filling of prescription should be done by the Pharmacist/ PharmacyAssistant and counterchecked by another Pharmacist.

3. Filling has to be done for new prescriptions and current prescriptionsin the CMR.

NOTESAmountAmountDate DateMEDICATION RECORD

PATIENT'S NAMEC16-B2 Ooi Chooi SengC16-B2 Ooi Chooi SengC16-B2 Ooi Chooi SengC16-B2 Ooi Chooi SengC16-B2 Ooi Chooi Seng

Date Start12/10/0912/10/0912/10/0912/10/0912/10/09

12/10/0912/10/0912/10/0912/10/0912/10/09 1 x 11 x 11 x 11 x 11 x 1

DRUGTab. Allopurinol 300mgTab. Allopurinol 300mgTab. Allopurinol 300mgTab. Allopurinol 300mgTab. Allopurinol 300mg

Prescriber'ssignature &stamp

Dose1/11/11/11/11/1

RoutePOPOPOPOPO

FrequencyDailyDailyDailyDailyDaily

Duration7/77/77/77/77/7


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4. Amount of medication and frequency supplied for the day should bewritten in the 'Amount' column of the CMR. [For example, Paracetamol1g (2 tablets) QID will be recorded as 2 x 4 as below]:

4 hourly 6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am

QID 6 am, 12 noon, 6 pm, 10 pm

TDS 8 am, 2 pm, 8 pm

BD 8 am, 8 pm

ON 10 pm

OM 8 am

Before meal 6 am

Before meal BD 6 am (before breakfast), 6 pm (before dinner)

prn Placed at the furthest end of the patient's bin.

Frequency Time


5. Pharmacy staff has to ensure the cleanliness of the medication trolleyand bins. All bins must be emptied before filling is done.

6. If there is a balance of medication in the patient's bin and no AdviceNote is given, explanation from the nurse on duty in the wardconcerned has to be obtained and recorded in the CMR.

7. One bin is allotted per patient. Each bin must be filled with themedication prescribed, with the correct quantity based on the CMRand in accordance with the administration times. Examples ofadministration times are as follows:

DATE AMOUNT DATE AMOUNT DATE AMOUNT NOTES

12/10/09 2 X 4

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8. For the dispensing of medications such as eye/ear drop solutions orcreams, the total volume or weight supplied must be recorded in the"amount" column and stamped with "TELAH DIBEKAL PADA". Forexample:

DATE AMOUNT

12/10/09 +8

13/10/09 +6

14/14/09 +2

9. Filling of prescriptions involving psychotropic medications,exchange basis drugs and floor stock items need not be done in aunit dose manner and the prescription should be stamped withEXCHANGE BASIS, USE PSYCHOTROPIC STOCK or USE FLOORSTOCK.

10. Use the "SELESAI" stamp after the prescriptions have beensupplied in full.

11. For prescriptions where dosage forms of the medication are changedfrom injection to oral, the CHANGE TO ORAL stamp should be usedand vice versa.

12. For PRN doses, the medications are placed at the back of theindividual bin. On the first day, the amount of doses supplied shouldbe recorded and for subsequent days, only the amount of dosesadded needs to be recorded.

Example 1: Tab. Paracetamol 1g PRN.


DATE AMOUNT DATE AMOUNT DATE AMOUNT NOTES

12/10/09 1 x 5ml

atau 1 x 30g

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TELAH DIBEKAL PADA

..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Example 2: Tab. Chlorpheniramine 4mg TDS & PRN


The staffs filling the bins have to sign the Unit Dose DispensingChecklist (Appendix 5).

2.1.5 Checking the Supply (Countercheck)

1. All unit dose medication supply must be counterchecked by a differentpharmacy staff from the one who did the filling.

2. All medication filling and counterchecking process must be donebefore the trolley collection time at 12.00 noon.

3. The nurse on duty should check the supply received and inform thepharmacy if there are any discrepancies.

4. After checking the supply, the nurse on duty should receive themedication trolley and acknowledge receipt in a form according tothe requirements of individual hospitals

5. All the filling errors need to be corrected and recorded for thepurpose of QAP Monitoring.

2.2 FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS

Wards are only permitted to keep a limited quantity of frequently-used medications. Amedication list which has been agreed upon by the pharmacy and the ward / unit shouldbe kept in the ward / unit and pharmacy. Level of floor stock / emergency trolley itemsshould be more than the minimum limit but should not exceed the maximum limit.Floor stock / emergency trolley medication list should be reviewed periodically.

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DATE AMOUNT

12/10/09 1 x 3 + 3

13/10/09 1 x 3 + 0 (not added)

14/14/09 1 x 3 + 2


The procedures for supplying Floor Stock / Emergency Trolley Medications are asfollow:

1. Receive medication order book from the ward / unit

2. Check balance of floor stock / emergency trolley medications

3. Record the quantity supplied in the order book

4. Supply medication according to the recorded quantity

5. File the original copy of the order book

2.3 AFTER OFFICE HOURS SUPPLY

Drugs prescribed after normal working hours will be supplied according to the amountrequested to the pharmacy staff on-call.

2.4 SUPPLY OF PSYCHOTROPIC MEDICINES

Wards may only keep psychotropic medicines in the amount permitted in a medicationlist. A copy of the medication list as agreed upon by the pharmacy and the ward / unitshould be kept in the ward / unit and pharmacy. Record books must be updated eachtime psychotropic medications are used based on valid prescription (order form).

The procedures for supply of psychotropic medicines are as follow:

1. Receive order form and psychotropic medications record book from the ward/ unit.

2. Check order form and record of psychotropic medication use

3. Determine that the order is consistent with use and record the balance ofpsychotropic medications

4. Record supply in the psychotropic medications register book

5. Record the quantity supplied and sign the psychotropic medications recordbook and order form

2.5 SUPPLIES FOR DISCHARGED PATIENTS

Supplies for discharged patients should follow the same procedures as that ofdispensing at the counter. However for medication counselling (refer Chapter 3.5) andbedside dispensing (refer Chapter 3.6), should ideally be carried out for the followingcategory of patients:


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1. Patients using devices (inhalers, insulin pen); to reinstate what has been taughtduring ward stay.

2. Patients with several debilitating conditions who are on many differentmedications.

3. Patients newly diagnosed with chronic illnesses

4. Patients on medications with narrow therapeutic index.

5. Patients who have poor understanding/knowledge/comprehension ofmedication usage / regimen

2.6 HANDLING REFERRAL LETTER (SECOND COPY) AND SUPPLY OFMEDICATIONS FOR PATIENTS BEING REFERRED TO HEALTH FACILITIES

The policy of Ministry of Health Malaysia stated that stable patients can be referred tonearby health facilities (hospital or health clinic) by using referral letter, for the purposeof continuing treatment. Proper handling of referral letter (second copy) and supply ofmedications to referred patients are important since not all facilities keep certainmedicines. Pharmacy Department is responsible in ensuring that there is a policy/procedure regarding the submission of referral letter (second copy) to Pharmacist atthe facility where the patient is referred to.

Objectives of proper handling of referral letter:

• To ensure preparedness of medications at the referred facility

• To ensure continuity of treatment

2.6.1 Referring patient by referring facility

1. The Medical Officer will fill in three copies of the referral letter(Appendix 6).

• The first copy is for the patient to bring to the referred facility

• The second copy is to be given to the Pharmacist at thereferring facility

• The third copy is to be kept in patient file at the referring facility

2. Pharmacist at the referring facility will review the patient's drugregiment with the Pharmacist at the referred facility

• If the referred facility does not keep the medicines, the referringfaci l i ty must supply enough medication unti l the nextappointment date at the referred facility

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W a r d P h a r m a c y A c t i v i t i e s 3.0

• Both Pharmacists should also discuss the patient's next supplyof medications

3. Pharmacist at the referring facility must fax or post the second copyof the referral letter to the Pharmacist at the referred facility, and ifnecessary supply the medications to the referred facility before thenext appointment date

4. A copy of the second copy of the referral letter should be filed forreference purposes

2.6.2 Receiving Second Copy at referred facility

1. Inform the referring facility upon receiving the second copy (andsupplied medications from the referring facility if necessary)

2. Review patient's drug regiment (and supplied medications from thereferring facility if necessary)

3. Register the patient's particulars into the Drug Supply Registry Book(Appendix 7)

4. File the second copy of the referral letter

5. Dispense medications on the fixed appointment date

2.7 WARD / UNIT INSPECTION

Ward Inspection is done to ensure the following:a. Ward stocks comply with the amount approved

b. Expiry dates of all drugs are clearly labelled

c. Drugs are properly labelled

d. Drugs are properly stored

e. Emergency drugs are available and in good order

f. Medication trolleys are checked regularly

g. Refrigerated items are stored appropriately

h. Psychotropic drugs are used, stored and recorded according to therequirements of existing laws

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Criteria for Good Drug Distribution Service

♦ Implementing the Unit Dose System

♦ Appropriate storage of Ward Stock

♦ Adequate Floor Stock level

♦ Complete range of Emergency Drugs

♦ Access to after office hours supply

♦ Routine Ward / Unit Inspection


Tips to Achieve Pharmaceutical Care Goals

♦ Establish and maintain professional relationships with patients and other healthcare teammembers.

♦ Collect, organise, record and maintain patient-specific medical information.

♦ Evaluate patient-specific medical information and develop good rapport with patients.

♦ Ensure that the patient has all supplies, information and knowledge necessary to carryout the drug therapy plan.

♦ Review, monitor and modify therapeutic plan when necessary and in concert with thepatient and healthcare team.

Ward Pharmacy activities should be in line with the concept of Pharmaceutical Carei.e. patient-centred, outcomes-oriented pharmacy practice. It requires the pharmacistto work in concert with other healthcare providers to promote health, to preventdisease, and to assess, monitor, initiate and modify medication towards ensuring thatdrug therapy regimens are safe and effective.

The goal of ward pharmacy activities is to optimise the patient's pharmacotherapy andachieve positive clinical outcomes within realistic economic expenditures. Four typesof forms are designed to document ward pharmacy activities:-

i. Medication History Assessment Form (CP1)

ii. Pharmacotherapy Review (CP2)

iii. Clinical Pharmacy Report Form (CP3) and

iv. Discharge Referral Note (CP4)

Ward pharmacy activities include the following:i. Medication History Taking

ii. Case Clerking

iii. Pharmacotherapy Rounds (including routine rounds, pharmacists' rounds andgrand ward rounds)

iv. Medication Reviewing

v. Medication Reconciliation

vi. Medication Counselling

vii. Discharge Planning

WARD PHARMACY ACTIVITIES3.0


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3.1 MEDICATION HISTORY TAKING

Medication history taking by pharmacists is essential for retrieving missing informationwith regard to prescription medications which the patient is currently on, informationon past drug history as well as self-medication. This additional information can be aninvaluable aid for pharmacists and other healthcare providers in assessing anddetermining the best treatment options towards optimising patient care.

Objectives of medication history taking:• To gauge the patient's understanding towards their medications

• To ensure continuity of medication treatment

• To elucidate information on non-compliance towards drug treatment

• To ascertain if patients are taking other forms of medications such assupplements, over-the-counter (OTC) medicines and herbal preparations.

The Medication History Assessment Form (CP1) should be used as a guide for effectivemedicine history taking. The form should be kept with the patient's case notes to serveas a reference for other healthcare providers.

3.0 W a r d P h a r m a c y A c t i v i t i e s

3.4 MEDICATION REVIEWING

Medication orders should be reviewed for incomplete prescriptions, inappropriate druguse, unclear instructions, authenticity of the prescriber, administration errors, appro-priate drug storage and other issues related to patient's drug management in the wardto determine the pharmacotherapeutic appropriateness of each order for the individualpatient.

3.5 MEDICATION RECONCILIATION

Important Points for Effective Medication History Taking

♦ List all current medications, including self-prescribed medication supplements and herbalpreparations with dosages and dates of commencement.

♦ Write down the medication history of previous treatment that may be relevant to the presenttreatment and any reason for changes or alterations in the regimen.

♦ Note history of allergy or adverse drug reactions to any particular drug / food.

♦ Assess compliance.

♦ Record any problem related to medications (e.g.: storage, supply, containers, labelling etc).

3.2 CASE CLERKING

Case clerking and medication review are often done concurrently. Most PCIs andpotential pharmaceutical interventions are identified during these two activities.Pharmacists should play an active role in recognising these issues and documentingthem into the case notes. If the PCI is significant to the patient's current medicationplan, the issue should be highlighted to other healthcare providers during ward roundsor wherever necessary. Efficient case clerking and reviewing require skills to keeppharmacists focused on the active pharmaceutical care plans and interventions.

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Skills for Efficient Case Clerking

♦ Able to extract relevant information from medication chart, case notes, laboratory data,Medication History Assessment Form and relevant details from patient interview

♦ Identify PCI

♦ Analyse relevant data according to specific pharmaceutical care issues (PCI)

♦ Differentiate PCIs from physician's management plan

♦ Possess relevant clinical knowledge

♦ Analyse relevant laboratory results

♦ Summarise clinical findings

Case clerking should be done for all new admissions as far as possible. The subsequentrevision of the case is known as case reviewing. Recurrent admissions should betreated as new admissions, thus requiring new case clerking to be performed. Allfindings, suggestions and interventions performed pertaining to PCIs during caseclerking / reviewing should be documented in the Pharmacotherapy Review Form (CP2)for continuous follow-up to achieve targeted pharmaceutical outcomes.

Once the form is completed, the case should be reviewed and updated on a dailybasis until the patient is discharged. Patient's progress should be monitored byanalysing objective and subjective parameters, updating current pharmaceutical careissues and intervening accordingly when necessary.

3.3 PHARMACOTHERAPY ROUNDS

Active participation in ward rounds requires good rapport with other healthcare teams,up to date knowledge on drugs and information on drug availability and dosage forms.The following 4P easy steps should be adapted to get started: Prepare, Participate,Perform and Prove.

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STEP 1: PREPARE

♦ Familiarise oneself with drugs commonly used in the ward. Create your own pocket-sizedrug referencee.g.: drug list, normal dose, dosage adjustment in renal/hepatic failure

♦ Review schedule for ward rounds

♦ Bring along necessary forms, documents, references and other helpful tool, e.g.: calculator,PDA, stamp

♦ Review medication chart and patient's progress notes to identify cases that need to bemonitored

STEP 2: PARTICIPATE

♦ Participate effectively during discussion by presenting relevant PCI.

♦ Practise diplomacy in dealing with patients and other healthcare providers.

♦ Be discreet about what is discussed in the presence of the patient and caregivers.

♦ Outline therapeutic plan, when required.

♦ Intervene when necessary and monitor outcome of intervention.

STEP 3: PERFORM

♦ Review patient's progress based on targeted outcome.

♦ Respond to questions and enquiries promptly.

♦ Follow up on pharmaceutical care interventions and review accordingly.

♦ Update patient's progress in the Pharmacotherapy Review Form.

STEP 4: PROVE

♦ Record all interventions and activities in the appropriate form.

♦ Keep all documentations in patient's folder for future reference.


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3.4 MEDICATION REVIEWING

Medication orders should be reviewed for incomplete prescriptions, inappropriate druguse, unclear instructions, authenticity of the prescriber, administration errors,appropriate drug storage and other issues related to patient’s drug management in theward to determine the pharmacotherapeutic appropriateness of each order for theindividual patient.

Medication Review Checklist

♦ Ensure that medication order is comprehensible and in accordance with local requirements

♦ Ensure that any drug / food allergens are documented / displayed prominently in thepatient's case notes / records

♦ Ensure appropriateness of medication order and administration times.

♦ Check whether dosages ordered have been administered.

♦ Detect any problem related to intravenous administration, including potential incompatibilities,drug stability, volume of intravenous fluid for medication administration and rate ofadministration

♦ Ensure that all ceased orders are cancelled in patient's drug profile drug order form

♦ Sign and date the chart after checking the above

3.5 MEDICATION RECONCILIATION

Medication reconciliation is a systematic process where all medications are correctlyand consciously continued, discontinued or modified in a timely manner at each pointin which the patient moves through the various levels of the health care continuum. Itis a formal process for creating the most complete and accurate list possible of apatient's current medications and comparing the list to those in the patient record ormedication order. Pharmacists should perform medication reconciliation at all pointsof care.

The objectives of the medication reconciliation are:i. To ensure that the most accurate patient medication list is available to all care

providers, especially at the point of transition of care (admission, transfer anddischarge). Transitions in care include changes in setting, service,practitioner or level of care.


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ii. To ensure timely and accurate documentation of a comprehensive list ofpatient's medications.

iii. To ensure communication of this information across the continuum of care.

iv. To reduce medication-related errors at each transfer of care.

v. To improve patient safety and optimise health outcomes.

3.6 MEDICATION COUNSELLING

Non-adherence to therapy can be due to various reasons such as patient's lack ofunderstanding, inappropriate / inadequate instructions, complicated regimens orfailure to fill a prescription. Ward pharmacists should conduct a patient-orientedinterview, review medications, make appropriate recommendations to prescribers and/ or patients themselves, and monitor patient outcome. Counselling is a professionalrelationship and activity which a pharmacist undertakes to enhance patients'knowledge on their pharmacotherapy and improve compliance to medications by givingprofessional advice, proper instructions and provision of aids where necessary.

There are various ways to conduct medication counselling - individual (bedside ordischarge) and group counselling. Bedside counselling is the counselling given to thepatients in the ward. Discharge counselling is the counselling given to the patient toensure that the patient/care-giver has a proper understanding of how to self-medicateupon discharge. Group counselling is counselling given to a group of patients withsimilar disease states. e.g. Warfarin group counselling, Diabetic group counselling,Cardiac Rehabilitation Program, etc.

Pharmacists' thorough understanding of the patient's condition and disease areessential in order to get the patients involved in their drug therapy plan duringmedication counselling. The pharmacist should ensure that the patient is counselledon all prescribed medicines and stress on the need to adhere to the prescribed regimen.This is especially important for patients with a history of poor compliance.

In designing an outcome-oriented drug therapy plan, the pharmacist should carefullyconsider the psychosocial aspects of the medical conditions as well as the potentialrelation between the cost and/or complexity of therapy and patient adherence.

The following information should be provided to the patient:• generic name and brand name of drugs prescribed

• intended purpose and expectation for a medication used

• dosage regimen

• route of administration of a medication


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• common side effects

• special directions or precautions for the preparation and administration of amedication

• information on relevant drug-drug, drug-food, drug-alcohol and drug test /procedure interactions

• storage conditions

• action to be taken in the event of a missed dose

Use the following easy steps for effective medication counselling.

STEP 1: PLAN

♦ Prioritise potential patient for counselling based on:

♦ Complexity of therapeutic plan♦ Compliance status♦ Patient with special device needs♦ Patient dependant on caregiver.

♦ Decide the type of counselling needed for each individual patient. For those with similarmedical problems / drug therapy, group counselling can be recommended.

STEP 2: PREPARE

♦ Study the patient medication profile, relevant medical history, social history and otherrelated information prior to counselling.

♦ Identify relevant issues to be emphasised during counselling.

♦ Develop an individualised outcome-oriented drug therapy plan.

♦ Select counselling tools (eg. flip chart, pamphlet, sample device etc).

♦ Schedule counselling session.

STEP 3: CONDUCT

♦ Educate on drug knowledge and disease.

♦ Discuss and educate patient's therapeutic plan.

♦ Enhance compliance to medication and treatment by having follow up sessions.


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Documentation and follow-up:

Follow-up counselling sessions may be necessary during ward stay and upondischarge. Information provided during the counselling sessions should be documentedin the case notes and Pharmacotherapy Review form (CP2) by the ward pharmacist.Counselling statistics should be recorded in the Clinical Pharmacy Report form (CP3).Patients who require continuity of care in other healthcare setting should be referredusing the Discharge Referral Note (CP4).

3.7 DISCHARGE PLANNING

Ensuring continuity of care when patients are transferred from one hospital to anotherinstitution requires effective cooperation between fellow pharmacists and doctors towhom responsibilities are transferred.

The objectives of discharge planning are:i. To reduce medication discrepancies after the patient is discharged from the

ward

ii. To save cost through the use of patients' own drugs

iii. To ensure better drug knowledge and to enhance compliance to medicinesprescribed

iv. To make provision for continuity of care.

3.7.1 Transcribing Discharge Medication into the Prescription

This activity should be done based on approval of the hospital managementand the doctors in charge of the ward. When a patient is ready to bedischarged, the doctor will write all the discharged medicines in the bed headticket (BHT). The ward pharmacist may take on the responsibility fortranscribing the medications which the patient is on into the prescription slip.

All discharged prescriptions should be initialled by the pharmacists, counterchecked by another pharmacist and signed by the attending physician. Thetranscribing of the discharge prescription will allow the doctor to save timeduring the process of discharging patients and will enable the patient to leaveearlier. However, the doctor must be fully aware that the final responsibility forthe prescription still lies with the doctor.

3.7.2 Preparation of Discharge Medications

Discharge Summary (Appendix 8) comprise of list of patients being dischargedon a particular day. It should be sent together with the dischargedprescriptions to the inpatient / satellite pharmacist, who is responsible for


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screening and counterchecking for any errors. If any error is detected, theinpatient / satellite pharmacist should call the ward pharmacist to do theintervention. Discharge medication will be prepared by the inpatient / satellitepharmacist and sent to the ward for bedside dispensing.

3.7.3 Use of Patient's Own Drugs for Discharge

By performing medication reconciliation, the ward pharmacist would haveknown if there is any balance medicines from the previous supply. If there isbalance of medication and is found to be in a good condition, it should bereused as far as possible. Any excess or remaining previous medications thatare discontinued in the ward should be returned to the pharmacy. The aim ofthis scheme is to optimize the use of current medications kept by patientsand reduce wastage.

3.7.4 Bedside Dispensing and Discharge Counselling

The objectives of this activity are:i. To speed up the patient’s discharge

ii. To enhance patient’s satisfaction

iii. To reduce number of patients at the outpatient department

iv. To promote better medicine knowledge and compliance

Bedside dispensing and discharge counselling will be done by the wardpharmacist. The ward pharmacist has to counsel the patient or familymembers on the medications prescribed, supply counselling aids (wherenecessary) and address any PCIs. Wards without a ward pharmacist canhave the medication dispensed by the inpatient pharmacist, or anypharmacists on duty according to schedule.


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OTHER ACTIVITIES4.0

Other activities in the Inpatient Pharmacy include the following:

4.1 Clinical Pharmacokinetic Service

4.2 Drug Information Service

4.3 Adverse Drug Reaction Monitoring and Reporting

4.4 Medication Error Reporting

4.5 Product Complaint Reporting

4.6 Processing Requests for Non-Formulary Medications

4.1 CLINICAL PHARMACOKINETIC SERVICE

Clinical Pharmacokinetic Service ensures safe and efficacious dosage regimensthrough the application of pharmacokinetic / pharmacodynamic principles and thedetermination of drug serum concentrations. At the same time this service providesinvaluable information regarding the toxicity level of the following drugs:

• Aminoglycosides (amikacin, gentamicin)

• Benzodiazepine

• Carbamazepine

• Digoxin

• Lithium

• Phenobarbital

• Phenytoin

• Theophylline

• Valproic acid

• Vancomycin

• Paracetamol

• Salicylates

• Tacrolimus

• Cyclosporine

4.0 O t h e r A c t i v i t i e s

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4.2 DRUG INFORMATION SERVICE

Pharmacists should serve as effective providers of drug information. All druginformation requests from healthcare professionals / consumer / patients should beresponded to immediately. By proper dissemination of drug information, the chancesof medication errors can be prevented. This service can improve awareness andknowledge on health among the public in the quality use of medicine and pharmaceuticalproducts. Moreover, it can promote patient care through rational use of drugs.

Enquiries may include the following categories:• Drug Availability

• Drug Identification

• Dosage/Administration

• Indication

• Interaction

• Contraindication / Precaution

• Adverse reactions / Side effects

All entertained enquiries should be properly documented to serve as future references.

4.3 ADVERSE DRUG REACTION MONITORING AND REPORTING

An Adverse Drug Reaction (ADR) is any unexpected, unintended, undesired, orexcessive response to a drug that:

• requires discontinuing the drug (therapeutic or diagnostic)

• requires changing the drug therapy

• requires modifying the dose (except for minor dosage adjustments)

• necessitates supportive treatment

• significantly complicates diagnosis

• negatively affects prognosis or

• results in temporary or permanent harm, disability or death

It is the pharmacist's responsibility to monitor and report any suspected adverse drugreactions (ADR).

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Process of Reporting by the Ward Pharmacist:

The occurrence of untoward reactions found to be caused or suspected to be causedby a drug should be investigated and verified. The event should be highlighted to theprescriber or pharmacist. The adverse drug reaction should be verified and an AdverseDrug Reaction report should be completed by the doctor or pharmacist. The DrugInformation Service (DIS) pharmacist should compile and submit the report to MalaysianAdverse Drug Reactions Advisory Committee (MADRAC). Reports may be submittedon-line or by posting the ADR form to MADRAC. Confidentiality of the reaction andpatient information must be maintained at all times. The Malaysian Guidelines forReporting and Monitoring of ADR can be obtained from the National PharmaceuticalControl Bureau NPCB) website.

A description of the adverse reactions and the suspected drug should be recorded inthe patient's bed head ticket / case note. The patient should be informed of the reactionand adequate advice given taking care to avoid legal implications. An allergy card shouldbe given to the patient for documentation and as a form of alert for future drug use. Thenumber of Adverse Drug Reaction events should be recorded in the Clinical PharmacyReport Form (CP3). The data should be analysed to study trends in the occurrence ofADRs to identify drugs which are commonly implicated, changes in the frequency ofoccurrence and at risk groups. This information should be presented to the Drugs &Therapeutics Committee if deemed necessary.

4.4 MEDICATION ERROR REPORTING

A medication error is defined as any preventable event that may cause or lead toinappropriate medication use or patient harm while the medication is in the control ofthe health care professional, patient, or consumer. Such events may be related toprofessional practice, health care products, procedures and systems, includingprescribing, order communication, product labelling, packaging and nomenclature,compounding, dispensing, distribution, administration, education, monitoring and use.

When reporting errors, please consider the following:1. Describe the error or preventable adverse drug reaction. What went wrong?

2. Was this an actual medication error (reached the patient) or are you expressingconcern about a potential error or writing about an error that was discoveredbefore it reached the patient?

3. Patient outcome

4. Type of practice site (hospital, private office, retail pharmacy, drug company,long-term care facility, etc)

5. The generic name (INN or official name) of all products involved

6. The brand name of all products involved

4.0 O t h e r A c t i v i t i e s

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ctivities


7. The dosage form, concentration or strength

8. How was the error discovered/intercepted?

9. Please state your recommendations for error prevention.

Pharmacist can refer to Guideline on Medication Error Reporting and submit the MEreport form (Appendix 12) to Pharmaceutical Services Division.

4.5 PRODUCT COMPLAINT REPORTING

Complaints on the quality, lack of efficacy, packaging, labelling, etc. of pharmaceuticalproducts by other healthcare professionals should be looked into by theward pharmacist. The reporter should fill in the Product Complaint Form (BPFK 418)and quarantine the related product. The DIS pharmacist should submit the form togetherwith the sample to the Centre for Product Post Registration, NPCB for further action.

4.6 PROCESSING REQUESTS FOR NON FORMULARY MEDICATIONS

Each hospital / institution should have its own drug formulary adapted from the MOHdrug formulary based on local needs and functions. The hospital formulary may notinclude all drugs in the MOH formulary. Newly-approved MOH drugs should follow thelocal hospital policy for inclusion into the hospital formulary. Formulary drugs shouldbe the preferred choice of use at all times.

Drugs not listed in the MOH formulary are called Non-MOH Formulary Medications andshould not be prescribed before getting prior approval from the Director General ofHealth. However, when non-hospital formulary drugs are strongly indicated (incircumstances such as life-threatening situations or no other alternatives are available),it should go through the proper procedure for approval before it can be obtained.

Ward Pharmacists in collaboration with the DIS pharmacist should ensure that non-MOH formulary drug requests for inpatients are rational and based on current evidence.The prescriber should submit the request by using the 'KPK 01' Form with justificationby the respective Head of Department. All requests should be submitted to thePharmaceutical Services Division, MOH for approval by the Director General of Health.The pharmacy department should monitor the non-MOH formulary drug usage once itis available in the hospital.

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Data collection through systematic documentation can be used for future planningand expansion of pharmacy services in the country. Drug information enquiries duringthe ward rounds should also be recorded in the Clinical Pharmacy Report Form. Areasof national importance such as cost savings and medication error reduction can beutilised to enhance a particular service. Please refer appendices for types of formsused in Inpatient Pharmacy Practice.

5.1 UNIT DOSE SYSTEM (UDS) FORMS

Please refer to Chapter 2.1 for the use of the UDS forms.

5.2 WARD PHARMACY FORMS

5.2.1 Medication History Assessment Form (CP1)

Introduction

As patients who are admitted to the ward may already be on some form ofmedication, it is important to obtain this information prior to initiating treatmentexcept in an emergency setting.

A patient's treatment may be improved by an accurate drug history whichhighlights drug related causes for previous treatment failure, previous andpotential adverse reactions, interactions, allergic, compliance, etc. Themedication history should be filed together with patients medical progress notes(original copy) and for pharmacy record (carbonized copy) to facilitate easyreference during the patient's stay in hospital.

Objectives

• To obtain a complete patient medication history within 24 hours of admissionin order to improve the provision of pharmaceutical care.

• To design a pharmaceutical care plan with the doctor and patient.

DOCUMENTATION5.0

5.0 D o c u m e n t a t i o n

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This form is divided into 5 sections:A. Patient BiodataB. Reason For AdmissionC. Allergy and Adverse Drug ReactionD. Drug HistoryE. Pharmacist Notes

How to Complete Form CP1:

A. Patient Biodata

• Obtain the patient's biodata (name, MRN, identity card number,address and contact number) and other required information (pastmedical history, admission date/time, ward of admission, themedical doctor in charge, diagnosis, last discharge/review date, lastencounter date at any hospital or clinic) from the Bed Head Ticket(BHT) or any of your hospital information retrieving system.

B. Reason for Admission

• Obtain information from patient or care giver

C. Allergy and Adverse Drug Reaction History

• Obtain allergy and adverse drug reaction history by interviewing thepatient or care giver and by reviewing past medical notes if available

• Record all confirmed, suspected and possible allergies and adversedrug reactions

• Record No Known Drug Allergy or NKDA if the patient has no historyor unknown drug allergy and adverse drug reaction

D. Drug History

• Obtain information on prescribed and non-prescribed medicationsincluding use of traditional/complementary medicines from thepatients or their caregiver

• Request the patient or care giver to bring prescribed andnon-prescribed home medications, which the patient is currently on

• Check the physical condition, label and dosage of the drugs and recordaccordingly in the form

• Obtain the actual dose regimen taken by patient and compare withthe dosing regimen on the label

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E. Pharmacist’s Notes

• Record patient's compliance status and their medications’ relatedproblem

• Plan pharmaceutical care interventions to improve patients' drugtherapy, compliance and understanding to treatment

5.2.2 Pharmacotherapy Review (CP2)

Introduction

Continuous pharmaceutical monitoring is essential to achieve optimum outcomefrom the care plan which has been designed for the patient.

Objectives

• To obtain a complete patient medication history within 24 hours ofadmission in order to improve the provision of pharmaceutical care.

• To plan, detect and monitor pharmaceutical care issues• To following on patient's response to the prescribed drug therapy• To update pharmacy-patient database for the purpose of discussion,

evaluation, as a learning tool as well as for the conduct of research,and studies

Form Contents

The form is divided into 5 main sections:• Section 1 - Appendix 10a : Patient's Profile• Section 2 - Appendix 10b & 10c : Patient's Medication• Section 3 - Appendix 10d &10e : Lab Investigations• Section 4 - Appendix 10f & 10g : Pharmaceutical Care Issues / Plan

/ Outcome• Section 5 - Appendix 10h : Discharge Medication

How to Complete Form CP2

• Section 1Obtain information from patient's BHT and Medication HistoryAssessment Form (Form CP1). If required interview patients forfurther information.


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• Section 2Obtain information of medications which the patient has beenprescribed / is on from the Medication Chart. Record complete drugregimen, date start and date stopped.

• Section 3Obtain information from BHT or Hospital Laboratory Data RetrievingSystem. Record significant lab values related to the pharmaceuticalcare plan and treatment goal.

• Section 4 (Monitor patient’s progress)Record all ongoing pharmaceutical care issues, therapeutic plan,therapeutic assessment and follow-up required.

• Section 5Record all discharged medication, and write the next appointmentdate.

5.2.3 Clinical Pharmacy Report Form (CP3)

Introduction

Data collection is critical towards justifying for the future expansion of clinicalpharmacy services and professional development and recognition in this country.

Objectives

• To document pharmaceutical interventions for the purpose of QualityAssurance Programme (QAP) monitoring.

• To record daily activities and workload of ward pharmacists.• To ensure continuity of pharmaceutical care in situations where

passing over of information is required when the primary pharmacistis away temporarily or off duty.

Forms Contents

This form is divided into 4 sections.


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Each form is to be filled on a daily or weekly basis depending on the practice inthe ward in individual hospitals.

A. Ward Pharmacy Activity

• Routine round is the daily ward round conducted by the wardpharmacists together with the medical officers. The specialist /consultant in charge may or may not attend.

• Grand round is the scheduled departmental round in which the wardpharmacists participate with the consultants, specialists, medicalofficers and nursing staffs.

• Pharmacists round is the pharmacotherapy ward round involving theward pharmacist with other fellow pharmacists.

• No. of cases clerked are the number of patients being clerked duringnew admissions.

• No. of cases reviewed are the clerked cases that are reviewed onthe following days.

• No. of patients in the ward are the total numbers of patients in theward on a particular day

B. Interventions / Requests Encountered

• This refers to pharmaceutical interventions where there is an actionthat produces an effect or alteration in optimizing patient'spharmacotherapy. Pharmaceutical interventions are divided into fourtypes namely Incomplete Prescription, Incorrect/ Inappropriate/Inadequate Regimen, Inappropriate Prescription and Miscellaneous.

• Examples of TDM interventions are; identification of patients whorequire TDM, advice on appropriate sampling time, suggestions ondosage adjustment based on the TDM results.

• Examples of TPN interventions are; recommendation for TPN therapy,suggestion for appropriate TPN regimen, changes made to TPNtherapy based on patient's response and outcome.

C. Description of Requests / Intervention Encountered

• This section summarises number of interventions done and numberof request / information provided as in section B.


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D. Follow Up Required

• This section is to transcribe any pharmaceutical care issues fromForm CP2 during clerking and medication reviewing for furtherfollow-up and clarification if required. This section is an importantmeans of communication to ensure the continuity of pharmaceuticalcare when the primary pharmacist is temporarily off duty or on leave.

5.2.4 Discharged Referral Note (CP4)

Introduction

The Discharge Referral Note (Appendix 12) should serve as a pharmacydischarge summary to be given to the primary care pharmacist or doctor. Thepatient should also be given the Discharge Referral Note for provision of furthercounselling and be informed that he / she is required to see the pharmacist in thefollow-up facility.


The ward pharmacist identifies patients who require further monitoring forreferral. The patient's diagnosis, medication list and discharge instructions inthe patient's case notes should be reviewed. Pharmacists should fill in theDischarge Referral Note (CP4 - Appendix 10) to ensure further reviewing orcounselling by the pharmacist in other healthcare setting takes place. All PCIsand action taken should be documented in the patient's case notes.


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Dooley, M. J., Allen, K. M., Doecke, C. J., et al. 2003. A ProspectiveMulticentre Study of Pharmacist Initiated Changes to Drug Therapy andPatient Management in Acute Care Government Funded Hospitals. Br.Journal Clinical Pharmacology, 2003 : 67;4 : 513-21.

Kok Thong Wong, Siang Kwang Lim, Ruhaiyem Yahaya et al. 2001.Guidelines Towards Excellence in Clinical Pharmacy Practice. PetalingJaya: Pharmaceutical Services Division, Ministry of Health.

Mohd Syafiq Abdullah, Kok Thong Wong, Rosnani Hashim et al. 1996.Clinical Pharmacy Practice in the Malaysian Health Service: Conceptand Manual. Petaling Jaya: Pharmaceutical Services Division, Ministryof Health.

Pharmaceutical Services Division, Ministry of Health. 2009. Requirementfor the Development of Pharmacy Faci l i t ies. Petal ing Jaya:Pharmaceutical Services Division, Ministry of Health.

REFERENCES6.0

6.0 R e f e r e n c e s

References


The forms used in Inpatient Pharmacy Practice are as follows:

• MR - Medication Chart Appendix 1

• CMR - Cumulative Medication Record Appendix 2

• Advice Note Appendix 3

• Intervention Note Appendix 4

• Unit Dose Dispensing Checklist Appendix 5

• Referral Letter Appendix 6

• Drug Supply Registry Book Appendix 7

• Discharge Summary Appendix 8

• CP1 -Medication History Assessment Form Appendix 9

• CP2 -Pharmacotherapy Review Appendix 10

• CP3 -Clinical Pharmacy Record Form Appendix 11

• CP4 -Discharge Referral Note Appendix 12

• Report on Suspected Adverse Drug Reaction Appendix 13

• Medication Error (ME) Report Form Appendix 14

• Product Complaint Form Appendix 15

APPENDICES7.0

A p p e n d i c e s 7.0

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Appendices

Appendices


Appendix 1

MEDICATION CHART

NAME : ................................................... AGE : ……………………………

I/C : ........................................................ WEIGHT : ..…………………………

R/N : ................................................... DIAGNOSIS : ..…………………………

WARD / BED : ……......................…….…. ALLERGY

MEDICATION RECORD Date Time Name/Ward/Bed Date

DRUG Prescriber'ssignature & stamp

Dose Route Freq Duration

Name/ Ward/ Bed Date












Note : original prescription (white) carbonised copy (yellow)

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Appendix 2

CUMULATIVE MEDICATION RECORD

PATIENT PARTICULAR

NAME : ................................................... AGE : ……………………………

I/C : ........................................................ WEIGHT : ..…………………………

R/N : ................................................... DIAGNOSIS : ..…………………………

WARD / BED : ……......................….…… ALLERGY

MEDICATION RECORD Date Amount Date Amount Date Amount Note

Appendices


Appendix 3

Inpatient PharmacyHospital ________________

ADVICE NOTE

Date :___________ Time :_________

Patient : _________________________________________________________________________

I.C. No. : _____________________________

R/N : ______________________

Ward : _____________ Bed No. : _______________

Age : ___________ years Weight : ________ kg

Diagnosis: _____________________________________________________

Dear Pharmacy staff,

With regards to this patient, we wish to advice the following:

New admission

Discharged / Deceased

Transferred – from Ward _______ Bed no. ________

to Ward _______ Bed no. ________

Medication stopped / changed ____________________________________________

______________________________________________________________________

Other ___________________________________________________________________

______________________________________________________________________

For pharmacy use only:

__________________________Sign & Stamp

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Appendix 4


INTERVENTION NOTE

__________________________________________________________________________________

Dear Doctor / Staff Nurse,

Kindly ammend this patient's prescription as per the following:

Specialist's signature required (for List A drugs)

LP form incomplete / required

Prescriber's signature missing

No CMR

Clarify drug name

Clarify patient's name / bed number

Other: ________________________________________

________________ ____________________________Date Sign & Stamp

Appendices


Appendix 5

Unit Dose Dispensing Checklist

Inpatient Pharmacy Service, Hospital ................................

WARD: YEAR: SATELLITE:

Month JANUARY FEBRUARY MARCH

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Received by:

Charted:

No. E

rrors:

Checked:

Dispensed:

Received by:

Charted:

No. E

rrors:

Checked:

Dispensed:

Received by:

Charted:

No. E

rrors:

Checked:

Dispensed:

Date

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Appendix 6

KEMENTERIAN KESIHATAN MALAYSIASURAT RUJUKAN

HOSPITAL ______________________

Rujukan mestilah kepada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital

Kepada : Jabatan / Unit :

Tarikh : Masa :

Nama Pesakit : Umur :

No.K/P : Jantina :

No. Rujukan Tuan : No. Rujukan Kami :

History & Physical Findings :

Results of Investigations :

Diagnosis :

Treatment :

Purpose of Referral :

Daripada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital

Nama : Tandatangan :

Hospital / Jabatan / Unit Tel :

Nota : Sila isi borang dalam 3 salinan

Salinan Pertama : Diberi kepada pesakit (untuk diberi kepada doktor di institusi yang dirujuk)

Salinan Kedua : Diberi kepada Pegawai Farmasi hospital merujuk (untuk difaks/ pos

kepada Pegawai Farmasi hospital / klinik dirujuk)

Salinan Ketiga : Disimpan dalam fail pesakit

Tarikh Temujanji:

Appendices


Appendix 7

Jumlah

TarikhNo Rujukan

BorangSumberRujukan(Hospitalasal yangmerujuk)

Bekalan Ubat Kategori A serta ubat-ubat yang tiada dalam formulari

(Tempoh Sebulan)

Nama dankekuatan

ubat

Kuantitidibekal

Kos (RM)

Tempohpesakitdirujuk

JumlahKos (RM)

BUKU DAFTAR PEMBEKALAN UBAT(Drug Supply Registry Book)

BAGI PESAKIT YANG DIRUJUK BAGI MENERUSKAN RAWATAN KEFASILITI KESIHATAN LAIN

Hospital / Klinik Kesihatan / Negeri : ____________________________

Tahun : _______________

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Appendix 8


DISCHARGE SUMMARY

Dear Pharmacy staff, WARD: __________

We wish to advice that the following patients have been discharged:

Bed No. Reg. No. Patient’s Name

For pharmacy use only: ___________________(Staff Nurse’s Name)

Date : _____________

Appendices


Appendix 9a

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Appendix 9b

Appendices


Appendix 10a

PHARMACOTHERAPY REVIEW

PHARMACOTHERAPY Pharmacy Department, Hospital ______________REVIEW Ref. no:

ALLERGY

Name : MRN : Age : Gender : M / F

Race : M / C / I / Others Ht/Wt : DOA : Ward/Bed :

Chief Complaint:

History of Present Illness:

Past Medical History: Review of system:

BP: mmHg RR: b/min

PR: p/min T: OC

Social/Family History: Smoking

Alcohol

Drug

Abuse

Pregnant

Past Medication History: Compliance Evaluation:

Diagnosis/Surgical Procedure:

Sign & Stamp:

Pind 1//10

CP2

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WARD MEDICATION

DRUG / REGIMEN DATE START DATE STOP

AN

TIB

IOTI

CC

AR

DIO

VAS

CU

LAR

ELE

CTR

OLY

TE T

HE

RA

PY

Appendix 10b

Appendices


WARD MEDICATION

DRUG / REGIMEN DATE START DATE STOP

INPUT

OUTPUT

BALANCE

DATE

Dopa

Dobu

Norad

Mida

Morp

Mida/Morp

Insulin

DIA

BE

TES

OTH

ER

SIN

FUS

ION

CH

AR

TI/O

CH

AR

T

Appendix 10c

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Day & Date 1 2 3 4 5 6 7N.Range

TWBC 4-11 x10/LHb 11.5-16.5 g/100mLRBC 4.5-6.3x106HCT 0.4/0.37-0.52/0.48Platlet 150-400 x10/L

Urea 1.7-8.3 mmol/LNa 135-145 mmol/LK 3.5-5.0 mmol/LCl 96-106 mmol/LCa 2.1-2.6 mmol/LMg 0.7-1.3 mmol/LPO4- 0.8-1.45 mmol/LSCr 64-122 umol/LClCr 105-150 mL/min

Albumin 35 - 50 g/LT.Bilirubin <20 umol/LT.Protein 66 - 87 g/LALP 53 - 141 u/LALT <32 u/L

PT 10-13.5 secAPTT 26 - 42 secINR <1.5

CK 24 - 195 u/lLDH 0 - 248 u/lAAT <37

pH 7.35-7.45pCO2 35-45mmHgpO2 72-100mmHgHCO3 22-29mmol/LO2 sat 90-95%

RBS < 11 mmol/L

BPTEMPRR 12 - 18 b/minPR 60 - 100 p/min

Date Date Sources/sample M/organism Sensitivity Resistant (sampling)

FBC

Oth

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BU

SE

/ R

enal

Pro

file

AB

GC

ardi

acen

zym

esC

oag.

prof

ileLi

ver

prof

ileC

&S

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Appendix 10d

Appendices


8 9 10 11 12 13 14 15 16 17 18 19 20

Date

T. Chol <5.7 mmol/LC-TG <1.7 mmol/LC-HDL >1.7mmol/LC-LDL <3.9 mmol/L

Lipi

d

Appendix 10e

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DATE PHARMACEUTICAL CARE ISSUES PHARMACIST RECOMMENDATION OUTCOME

Appendix 10f

Appendices


DATE PHARMACEUTICAL CARE ISSUES PHARMACIST RECOMMENDATION OUTCOME

Appendix 10g

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DISCHARGE MEDICATION

NEXT TCA:

Appendix 10h

Appendices


Appendix 11a

CP3CLINICAL PHARMACY REPORT FORMPharmacy Department, Hospital ……………………..

A: WARD PHARMACY ACTIVITYDate : Routine RoundsWard : Grand RoundsTask : Full Time / Part Time Pharmacist RoundsPhysician(s) : Number of Cases Clerked

Number of Cases Reviewed Number of Patients in Ward Number of Medication History (CP1) Taken

B: INTERVENTIONS / REQUESTS ENCOUNTERED

Interventions Description Number of Number of Request / Information Number Total interventions interventions Provided

accepted(1)

IncompletePrescription

(2)Incorrect/

Inappropriate/Inadequate

Regimen

(3)InappropriatePrescription

(4)Miscellaneous

Patient dataDrugDoseFrequencyDurationDr’s Stamp & SignDrugDoseFrequencyDurationPolypharmacyContraindicationDrug InteractionIncompatibilityUnclear HandwritingAuthenticity ofPrescription/PrescriberDrug AdministrationErrorSuggest For VitalSigns Monitoring/LaboratoryInvestigationTDMTPN

Adverse Drug ReactionDrug ToxicityDrug DosageTherapeutic EfficacyDrug IndicationDrug InteractionPharmacokineticTPNGeneral Product InformationPharmaceutical AvailabilityPharmaceutical CompatibilityPharmaceutical Identification

TOTAL INFORMATIONPROVIDED

TOTAL INTERVENTIONS

Bedside Counselling

Discharge Counselling

Group Counselling

GRAND TOTAL

COUNSELLING Number Total No. Of Of Sessions Patients

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Appendix 11b

C: DESCRIPTION OF REQUESTS / INTERVENTIONS ENCOUNTERED

D: FOLLOW-UP REQUIRED

No FOLLOW-UP CHECKLIST SIGN

…………………………..Pharmacist Sign & StampDate:

Pin. 1/10


DISCHARGE REFERRAL NOTE

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Appendix 12


Appendix 13

Appendices


Appendix 14

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Appendices

BORANG LAPORAN ADUAN PRODUKYANG BERDAFTAR DENGAN PIHAK BERKUASA KAWALAN DADAH

Product Complaint Form for Products Registered with the Drug Control Authority

SILA KEMUKAKAN SAMPEL ADUAN BERSAMA DENGAN BORANG INIPlease send complaint samples with this form

i. MAKLUMAT PRODUK Particulars of Product

NAMA PRODUK:Name of ProductNO. PENDAFTARAN PBKD/MAL: NO. KELOMPOK:Registration Number Batch NumberTARIKH DIKILANGKAN: TARIKH LUPUT:Manufacturing Date Expiry Date

ii. BUTIR-BUTIR ADUAN LENGKAP Sila isikan bahagian yang berkenaan Please fill in the details according to the nature of the complaint

ADUAN KUALITI:Complaint on product quality

………………………………………………………………………….................................................... …………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………

ADUAN EFIKASI:Complaint on product efficacyBagi masalah efikasi, kerjasama tuan/puan diminta supaya memberi maklumbalas objektif seperti:-- % pesakit yang menghadapi masalah- Adakah masalah berlaku selepas “brand switching”- “Objective findings” seperti BP reading, RBS dll yang boleh menyokong aduan bahawa produk

kurang berkesan.Kindly provide us with objective feedback such as:- % patients having similar problems- Was the problem occurring after brand switching- Objective findings such as BP reading, RBS etc to support the complaint on the efficacy of the product........……………………………………………………………………………………………………………….

……………………………………………………………………………………………………………….………………………………………………………………………………………………………...........................

iii. MAKLUMAT PELAPOR Particulars of Complainant

NAMA: JAWATAN/PEKERJAAN:Name Designation/OccupationALAMAT LENGKAP TEMPAT KERJA:Address

TELEFON: FAX:Telephone FaxTANDATANGAN: TARIKH:Signature Date

Sila hantar kepada: SEKSYEN SURVEILANS & ADUAN PRODUKPlease send to: PUSAT PASCA PENDAFTARAN PRODUK

BIRO PENGAWALAN FARMASEUTIKAL KEBANGSAANKEMENTERIAN KESIHATAN MALAYSIAJALAN UNIVERSITI, PETI SURAT 31946730 PETALING JAYAFax: 603-79567151

Appendix 15


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1. Dose regimen - A complete information on name of drug, mode of administration,dosage, frequency and duration

2. Compliance aid - Any device such as pillbox, pamphlet or timetable guide thathelps to improve the patient's compliance to medication

3. Pharmaceutical Care issue (PCI) - Any problems related to patients' diseasesand drug treatment conditions

4. Single Ward - Only one individual ward

5. Counseling - A professional relationship and activity through which a pharmacistendeavours to educate patients on their pharmacotherapy and enhancecompliance to medications by giving professional advice, opinion and instructions.

6. Bedside counseling - Counseling given to patient who is in the ward

7. Discharge counseling - Counseling given to patient upon discharge

8. Group counselling - Counseling given to a group of patient who has similarity indisease state

9. QAP - Quality assurance programme

10. PF - Pengurusan Farmasi is an indicator for monitoring the workload andperformance of the activities in the pharmacy services.

11. Routine round - Daily ward round between the ward pharmacists, medical officerwith or without the specialist or consultant.

12. Grand round - Scheduled departmental round participated by the ward pharmacistswith the consultants, specialist, medical officer and nursing staff.

13. Pharmacists round - Pharmacotherapy ward round involving the ward pharmacistwith other fellow pharmacists.

14. No. of cases clerked - Cases clerked for the first time during the current admission

15. No. of cases reviewed - Clerked cases that are reviewed on the following days

16. Chief complaints (CC) - Main complaints made by the patients during admission. Itshould be documented as layman term

GLOSSARY8.0


Glossary

17. History of present illness (HPI)• Presenting symptoms and time scale of their occurrence• Date of presentation to hospital or clinic• Mode of admission eg. Acute emergency or referral

18. Past medical history (PmHx)• Past medical problems listed, emphasizing those relevant to the case and

with attention to accurate sequence and timing of events including previousadmissions to hospital and specialist referrals

19. Social history (SHx)• Smoking and alcohol habits, social circumstances including social & family

support• Unusual living conditions, travel or habits where these may be relevant to the

patient's medical condition

20. Family history (FHx)• Relevant familial illness especially premature deaths of parents or siblings

21. FUKKM - Formulasi Ubat, Kementerian Kesihatan Malaysia is a list of a drugformulary under Ministry of Health

22. Health Facility - Hospital, Health Clinic and Health Institution under Ministry ofHealth

23. Second Copy - a referral letter that is used to refer patient from one facility toanother

24. LP form - Local Purchase Form

25. DOA - Date of Admission

26. TDM - Therapeutic Drug Monitoring

guidelines for inpatient pharmacy practicejknj.moh.gov.my/farmasi/garispanduan/[2010] guidelines...

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