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    TDM Request Form

    Uploaded by

    Wildan Setyo Rayandi
    This document is a therapeutic drug monitoring request form containing a patient's clinical information. It includes the patient's name, age, weight, and diagnosis. It lists the patient's current medications and recent lab results. The form requests analysis of specific drug levels and provides spaces for the prescribing doctor's signature and the analyzing pharmacist's assessment and recommendation.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    TDM Request Form

    Uploaded by

    Wildan Setyo Rayandi
    1K views3 pages
    This document is a therapeutic drug monitoring request form containing a patient's clinical information. It includes the patient's name, age, weight, and diagnosis. It lists the patient's current medications and recent lab results. The form requests analysis of specific drug levels and provides spaces for the prescribing doctor's signature and the analyzing pharmacist's assessment and recommendation.

    Original Title

    TDM Request Form.xlsx

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    This document is a therapeutic drug monitoring request form containing a patient's clinical information. It includes the patient's name, age, weight, and diagnosis. It lists the patient's current medications and recent lab results. The form requests analysis of specific drug levels and provides spaces for the prescribing doctor's signature and the analyzing pharmacist's assessment and recommendation.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    1K views3 pages

    TDM Request Form

    Uploaded by

    Wildan Setyo Rayandi
    This document is a therapeutic drug monitoring request form containing a patient's clinical information. It includes the patient's name, age, weight, and diagnosis. It lists the patient's current medications and recent lab results. The form requests analysis of specific drug levels and provides spaces for the prescribing doctor's signature and the analyzing pharmacist's assessment and recommendation.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
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    THERAPEUTIC DRUG MONITORING (TDM) REQUEST FORM

    PATIENT PROFILE
    Name : Ward / Unit : RN/IC :
    Age : years Sex : Male / Female Race :
    Weight (kg) : Height (cm) : DOA :
    CLINICAL SUMMARY AND DIAGNOSIS

    PATIENT CONDITION INDICATION FOR REQUEST


    □ Oedema □ Smoker □ Dehydration □ Therapeutic Monitoring □ Poor Response
    □ Dialysis □ Burn □ Liver Disease □ Suspected Toxicity □ Non Compliance
    LATEST LAB RESULT CONCURRENT MEDICATION
    Date Result
    Blood Urea
    Na₊ / K-
    Creatinine
    Albumin
    Drug Analysis Date Time
    Present Dose Regimen
    Tick (V) where Appropriate Started Last Dose Pre-sampling Dose Given Post Given
    Acetaminophen
    Amikacin
    Digoxin
    Carbamazepin
    Gentamicin
    Phenobarbitone
    Phenytoin
    Salicylate
    Theophylline
    Valproic Acid
    Vancomycin
    Cyclosporin
    Refer to TDM Serum Sample Guide
    For injectable drug being analysed :
    Infusion rate :
    Duration of Infusion :
    Doctor's Signature Name & Stamp Date
    Drug Analysis Result Normal Therapeutic Range Pharmacokinetic Profiles Date Received:
    K :
    T ₁⁄₂ : Time Received:
    Vd : Test Done :
    Cr CL : Initials :
    Pharmacist's Assessment and Recommendation:
    Informed : ……………………………………….. on ……………………… at ………. am/pm Pharmacist's signature & Stamp
    ₊

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