Scribd
Upload
96 views2 pages

ADR Form

Uploaded by

Aman Upadhyay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
96 views2 pages

ADR Form

Uploaded by

Aman Upadhyay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

DEPARTMENT OF PHARMACY PRACTICE – TMCOP

TEERTHANKER MAHAVEER MEDICAL COLLEGE HOSPITAL


MORADABAD, UP

ADVERSE DRUG REACTION REPORTING AND DOCUMENTATION FORM

Patient Name: HP No: Department:


Age: Sex: Weight: IP/OP: Unit:
Reason for admission:
Known allergies:
Brief description of reaction:

Date of onset of treatment: Date of onset of Reaction:

Drugs used Tick


Date Route and
prior to Dose suspected Indication Date stopped
started Frequency
reaction drug(s)

Management of Adverse Drug Reaction:


 Drug withdrawn  Dose altered  No change

Treatment given:
 Specific  Symptomatic  Nil

Outcome:  Fatal  Recovery Continuing


 Unknown  Other

Dechallenge: Rechallenge:
 No dechallenge  No rechallenge
 Definite improvement  Recurrence of symptoms
 No improvement  No occurrence of symptoms
 Unknown  Unknown

Follow up:
Patient interviewed:  Yes  No

Thank you note provided:  Yes  No  N/A

Alert card provided:  Yes  No  N/A

Causality:

A) Naranjo’s Scale
 Definite  Possible
 Probable  Unlikely

C) WHO Scale
 Certain  Unassessable/Unclassifiable
 Probable  Unlikely
 Possible  Conditional/Unclassified

Severity (Hartwing et.al. Scale):


Mild: Moderate: Severe:
 Level 1  Level 3  Level 5
 Level 2  Level 4 (a)  Level 6
 Level 4 (b)  Level 7

Predictability:
 Predictable  Non Predictable

Preventability: (Modified Schumock and Thronton’s Scale):


 Definitely Preventable  Probably Preventable  Not Preventable

Predisposing Factors:
 Age  Gender  Genetic
 Intercurrent Disease  Multiple Drug Therapy  Others (specify)

References consulted:

Name of the Attending Pharmacist: Signature:

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy