Guidelines For Inpatient Pharmacy Practice

PHARMACEUTICAL SERVICES PHARMACEUTICAL SERVICES DIVISION MINISTRY HEALTH MALA MINISTRY OF HEALTH MALAYSIA
GUIDELINES FOR INPATIENT PHARMAC Y PRACTICE

Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
First Print, 2010 Pharmaceutical Services Division, Ministry of Health, Malaysia.
ALL RIGHTS RESERVED No part of this publication may be reproduced, stored or transmitted in any form or by any means whether electronic, mechanical, photocopying, tape recording or others without written permission from the Senior Director of Pharmaceutical Services, Ministry of Health, Malaysia.
Perpustakaan Negara Malaysia Guidelines for Inpatient Pharmacy Practice, Ministry of Health Malaysia. ISBN 978-967-5570-12-4
PREFACE
Director Pharmacy Practice and Development Division Ministry Of Health Malaysia
Pharmacy Practice and Development Division has been evolving and this is evidenced through years of excellence in performance. Primarily focussed on patient safety, we are responsible for the optimisation of drug therapy and prevention of medication errors. Throughout the expansion of services, Pharmacy Practice and Development Division has introduced standardisation of procedures towards assisting proper management of Drug Distribution and Ward Pharmacy activities. This Guidelines for Inpatient Pharmacy Practice will serve as a tool for all to work conscientiously for the benefit of patients. This guideline focuses on good management of drug distribution describes work flows of the Inpatient Pharmacy processes and explanation of the necessary documents involved. It is hoped that the guidelines are able to steer good management practice in conducive environments towards fulfilment of customers' needs. I would like to convey my gratitude to the Clinical & Technical Pharmacy Working Committee in the success of producing this guideline. Also, a special thanks to all parties that contributed during all stages of development and publication of this guideline. Thank you
Hasnah binti Ismail Director, Pharmacy Practice and Development Division, Ministry of Health Malaysia.
Table of Contents
Preface Table of Contents Editorial Board 1.0 Inpatient Pharmacy Services 2.0 Drug Distribution Activities
2.1 2.2 2.3 2.4 2.5 2.6 Unit Dose System Floor Stock / Emergency Trolley Medications After Office Hours Supply Supply of Psychotropic Medicines Supplies for Discharged Patients Handling Referral Letter (Second Copy) and Supply of Medications for Patients being referred to Health Facilities Ward / Unit Medication Inspection
Page
3 4 5 9 10 10 16 17 17 17 18 19 21 22 22 23 25 26 24 28
2.7
3.0 Ward Pharmacy Activities

3.1 3.2 3.3 3.4 3.5 3.6 3.7 Medication History Taking Case Clerking Pharmacotherapy Rounds Medication Review Medication Reconciliation Medication Counselling Discharge Planning
4.0 Other Activities

4.1 4.2 4.3 4.4 4.5 4.6 Clinical Pharmacokinetic Service Drug Information Service Adverse Drug Reaction Monitoring and Reporting Medication Error Reporting Product Complaint Reporting Processing Request for Non-Formulary Medications
30 31 31 32 33 33 34 40 41 67
5.0 Documentations 6.0 Reference 7.0 Appendices 8.0 Glossary
Editorial Board
Advisors
Eisah A Rahman Senior Director of Pharmaceutical Services, Ministry of Health Malaysia Hasnah Ismail Director of Pharmacy Practice and Development Pharmaceutical Services Divison, MOH
Editors
Abida Haq Syed M. Haq Deputy Director Pharmaceutical Services Division, MOH Ainul Salhani Abdul Rahman Principal Assistant Director Pharmaceutical Services Division, MOH Rabi'ah Mamat Principal Assistant Director Pharmaceutical Services Division, MOH Phuar Hsiao Ling Senior Assistant Director Pharmaceutical Services Division, MOH
GUIDELINES FOR INPATIENT PHARMAC Y INPA PHARMAC PRACTICE PRACTICE
Inpatient
Pharmacy
Services
1.0
Pharmaceutical care is an area in the health care system which has yet to be fully developed in Malaysia although it has generated tremendous impact worldwide. Since its inception in the 1990's, Malaysian pharmacists have embarked on a bold and dramatic leap forward to embrace its philosophy in all areas of pharmaceutical care services. Much effort has been put into exploring ways in which to instil and initiate pharmaceutical care activities in both the outpatient and inpatient settings. Ward pharmacy activities encompass issues on all aspects of pharmacotherapy. During ward rounds, input pertaining to appropriateness of therapy, counselling of patients on medication therapy and the monitoring of unwanted side effects are the major services provided. Often time, the input given is not documented. Thus, a mechanism to document these activities is crucial and urgently required. The pharmaceutical needs of a patient refer to his or her requirements for pharmaceutical products or services. Pharmaceutical needs may be identified by any member of the health care team or by the patient him/herself. Once a targeted patient group has been assigned to the responsibility of a clinical pharmacist, a function of the delivery of the service is to prioritise the individual patient in the group according to his/her potential pharmaceutical care issues (PCI). It is important to document the outcomes of the pharmaceutical care intervention for the purpose of individual patient records as well as information for the management. Information on issues such as drug availability, dosage form, procurement and storage should be managed in liaison with colleagues in other units. Pharmacists require both knowledge and clinical experience to be a useful member of the health care team. Therefore the clinical pharmacist serves as a liaison person between patients, doctors, nurses and fellow pharmacists.
Inpatient Pharmacy Services
1.0
INPATIENT PHARMACY SERVICES
2.0
Drug
Distribution
Activities
2.0
Objectives
DRUG DISTRIBUTION ACTIVITIES
The pharmacy department should implement a distribution system that meets the following objectives: i. To dispense prescribed drugs to patients in wards in a timely and efficient manner 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 Activities
Drug Distribution Method Currently, three types of drug distribution systems are being practiced i.e. the traditional 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 dispensing of drugs to individual patients on a daily basis and for 24 hour duration only. The unitof-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 location and 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 labelled drawers or trays in the medication trolleys for patients. The amount of medication dispensed should be according to the dosage regimen and placed in compartments within the patient drawers. The medication trolley must be lockable and the keys kept by a registered nurse in the specific ward and another by an authorised pharmacy staff. 10
Drug
Distribution
Activities
2.0
2.1.1
Handling of Medication Trolley 1. The medication trolley should be sent to the pharmacy by the nurse on duty for the supply of new prescriptions and daily refilling of current prescriptions after dose administration times, usually at 8.00am. 2. The trolley has to be collected by ward staff before the next dose administration time at 12.00 noon.
2.1.2
Medication Order 1. The medication order for ward patients must be completed in the self-carbonised Medication Chart and signed by the prescriber according to the categories set by the Ministry of Health Malaysia Drug Formulary (FUKKM). 2. Each prescription must be written with the generic name, complete with 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 be stamped and countersigned by the relevant specialist. Controlled medicines must be attached with application forms according to the practice in individual institutions. 4. All original prescriptions (white) from the Medication Chart should be separated from the carbonised copy (yellow) (Appendix 1). The carbonised copy should be retained in the ward. 5. A new medication order (prescription) must be made in the following situations: a) Newly-admitted patients b) Patients transferred in from other wards c) Patients who have just undergone an operation or special procedures d) Expired prescriptions but treatment needs to be continued 6. For patients who have just been admitted into the ward, the prescription has to be sent with the patient's Cumulative Medication Record (Appendix 2). 7. For patients currently in the ward, any addition of medications must be made through a prescription. Any changes in dose, dosage form, frequency or treatment duration warrants a new prescription attached with an Advice Note (Appendix 3).
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2.0
Drug
Distribution
Activities
8. The completed original prescription must be separated from the self-carbonised copy, collected and sent to the pharmacy. 9. The nurse on duty is responsible for sending prescriptions for all patients in the ward to the pharmacy. Under certain circumstances, the nurse can direct the Penolong Perawatan Kesihatan (PPK) to send 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 to ensure the following: a) Authenticity of prescription/prescriber b) Adherence to FUKKM c) Suitability of dosing regimen d) Drug interactions e) Polypharmacy f) Correct medication administration method and frequency g) Others 3. For any other interventions, the Pharmacist/ Pharmacy Assistant should either contact the medical officer concerned for clarification or issue an Intervention Note (Appendix 4). 4. Any changes made to the prescription can only be made with the prior consent of the prescriber concerned and recorded into the 'Notes' column of the CMR. If the countersignature for Category A medications has not been obtained, the prescription should be copied into the CMR and the medication supplied first while waiting for the countersignature. The Intervention Note that states the necessity for the specialist's signature should be sent to the ward with the prescription. After it is signed, the prescription will be returned to the pharmacy to be pasted on the CMR.
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Distribution
Activities
2.0
5. All new prescriptions which have been screened should be pasted on the patient's CMR and the expiry date of the prescription recorded in the amount column. For example: MEDICATION RECORD
PATIENT'S NAME
C16-B2 Ooi Chooi Seng
Date
Amount
1 x 1
Date
Amount
NOTES
Date Start
12/10/09
12/10/09
DRUG
Tab. Allopurinol 300mg
Prescriber's signature & stamp
Dose
1/1
Route
PO
Frequency Duration
Daily 7/7
6. To discontinue a medication, the prescription at the CMR must be stamped with "UBAT DIBERHENTIKAN". At the Medication Chart (yellow copy) in the ward, the prescriber/pharmacist/nurse can record the discontinuation of the medication in the yellow copy. 7. To withhold medication, it must be recorded as "WH" in the CMR at the amount column. The same should be done for the Medication Chart in the ward, which should be done by the doctor/ pharmacist/ nurse. 8. Changes in medication dose or administration frequency need to be stamped with "RUJUK PRESKRIPSI BARU". 2.1.4 Filling of Prescriptions 1. All medications supplied to the ward must be in ready-to-use form in a container meant for administration of one dose and not exceeding the requirements for 24 hours. 2. Filling of prescription should be done by the Pharmacist/ Pharmacy Assistant and counterchecked by another Pharmacist. 3. Filling has to be done for new prescriptions and current prescriptions in the CMR.
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4. Amount of medication and frequency supplied for the day should be written in the 'Amount' column of the CMR. [For example, Paracetamol 1g (2 tablets) QID will be recorded as 2 x 4 as below]:
DATE 12/10/09
AMOUNT DATE 2X4
AMOUNT DATE
AMOUNT NOTES
5. Pharmacy staff has to ensure the cleanliness of the medication trolley and 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 Advice Note is given, explanation from the nurse on duty in the ward concerned has to be obtained and recorded in the CMR. 7. One bin is allotted per patient. Each bin must be filled with the medication prescribed, with the correct quantity based on the CMR and in accordance with the administration times. Examples of administration times are as follows:
Frequency
4 hourly QID TDS BD ON OM Before meal Before meal BD prn
Time
6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am 6 am, 12 noon, 6 pm, 10 pm 8 am, 2 pm, 8 pm 8 am, 8 pm 10 pm 8 am 6 am 6 am (before breakfast), 6 pm (before dinner) Placed at the furthest end of the patient's bin.
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2.0
8. For the dispensing of medications such as eye/ear drop solutions or creams, the total volume or weight supplied must be recorded in the "amount" column and stamped with "TELAH DIBEKAL PADA". For example:
12/10/09 1 x 5ml atau 1 x 30g
TELAH DIBEKAL PADA
............................................................... ...............................................................
9. Filling of prescriptions involving psychotropic medications, exchange basis drugs and floor stock items need not be done in a unit dose manner and the prescription should be stamped with EXCHANGE BASIS, USE PSYCHOTROPIC STOCK or USE FLOOR STOCK. 10. Use the "SELESAI" stamp after the prescriptions have been supplied in full. 11. For prescriptions where dosage forms of the medication are changed from injection to oral, the CHANGE TO ORAL stamp should be used and vice versa. 12. For PRN doses, the medications are placed at the back of the individual bin. On the first day, the amount of doses supplied should be recorded and for subsequent days, only the amount of doses added needs to be recorded. Example 1: Tab. Paracetamol 1g PRN.
DATE
12/10/09 13/10/09 14/14/09
AMOUNT
+8 +6 +2
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DATE
AMOUNT DATE
AMOUNT DATE
AMOUNT NOTES
2.0
Drug
Distribution
Activities
Example 2: Tab. Chlorpheniramine 4mg TDS & PRN DATE

12/10/09 13/10/09 14/14/09
AMOUNT
1x3+3 1 x 3 + 0 (not added) 1x3+2
The staffs filling the bins have to sign the Unit Dose Dispensing Checklist (Appendix 5). 2.1.5 Checking the Supply (Countercheck) 1. All unit dose medication supply must be counterchecked by a different pharmacy staff from the one who did the filling. 2. All medication filling and counterchecking process must be done before the trolley collection time at 12.00 noon. 3. The nurse on duty should check the supply received and inform the pharmacy if there are any discrepancies. 4. After checking the supply, the nurse on duty should receive the medication trolley and acknowledge receipt in a form according to the requirements of individual hospitals 5. All the filling errors need to be corrected and recorded for the purpose of QAP Monitoring.
2.2
FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS
Wards are only permitted to keep a limited quantity of frequently-used medications. A medication list which has been agreed upon by the pharmacy and the ward / unit should be kept in the ward / unit and pharmacy. Level of floor stock / emergency trolley items should 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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Drug
Distribution
Activities
2.0
The procedures for supplying Floor Stock / Emergency Trolley Medications are as follow: 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 amount requested to the pharmacy staff on-call.
2.4
SUPPLY OF PSYCHOTROPIC MEDICINES
Wards may only keep psychotropic medicines in the amount permitted in a medication list. A copy of the medication list as agreed upon by the pharmacy and the ward / unit should be kept in the ward / unit and pharmacy. Record books must be updated each time 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 of psychotropic medications 4. Record supply in the psychotropic medications register book 5. Record the quantity supplied and sign the psychotropic medications record book and order form
2.5
SUPPLIES FOR DISCHARGED PATIENTS
Supplies for discharged patients should follow the same procedures as that of dispensing at the counter. However for medication counselling (refer Chapter 3.5) and bedside dispensing (refer Chapter 3.6), should ideally be carried out for the following category of patients:
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2.0
Drug
Distribution
Activities
1. Patients using devices (inhalers, insulin pen); to reinstate what has been taught during ward stay. 2. Patients with several debilitating conditions who are on many different medications. 3. Patients newly diagnosed with chronic illnesses 4. Patients on medications with narrow therapeutic index. 5. Patients who have poor understanding/knowledge/comprehension of medication usage / regimen
2.6
HANDLING REFERRAL LETTER (SECOND COPY) AND SUPPLY OF MEDICATIONS FOR PATIENTS BEING REFERRED TO HEALTH FACILITIES
The policy of Ministry of Health Malaysia stated that stable patients can be referred to nearby health facilities (hospital or health clinic) by using referral letter, for the purpose of continuing treatment. Proper handling of referral letter (second copy) and supply of medications to referred patients are important since not all facilities keep certain medicines. Pharmacy Department is responsible in ensuring that there is a policy/ procedure regarding the submission of referral letter (second copy) to Pharmacist at the 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 the referring 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 drug regiment with the Pharmacist at the referred facility
If the referred facility does not keep the medicines, the referring facility must supply enough medication until the next appointment date at the referred facility
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Pharmacy
Activities
3.0
Both Pharmacists should also discuss the patient's next supply of medications
4. A copy of the second copy of the referral letter should be filed for reference purposes 2.6.2 Receiving Second Copy at referred facility 1. Inform the referring facility upon receiving the second copy (and supplied medications from the referring facility if necessary) 2. Review patient's drug regiment (and supplied medications from the referring 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 the requirements of existing laws
19
3. Pharmacist at the referring facility must fax or post the second copy of the referral letter to the Pharmacist at the referred facility, and if necessary supply the medications to the referred facility before the next appointment date
2.0
Drug
Distribution
Activities
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
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Ward
Pharmacy
Activities
3.0
3.0
WARD PHARMACY ACTIVITIES
Ward Pharmacy activities should be in line with the concept of Pharmaceutical Care i.e. patient-centred, outcomes-oriented pharmacy practice. It requires the pharmacist to work in concert with other healthcare providers to promote health, to prevent disease, and to assess, monitor, initiate and modify medication towards ensuring that drug therapy regimens are safe and effective. The goal of ward pharmacy activities is to optimise the patient's pharmacotherapy and achieve positive clinical outcomes within realistic economic expenditures. Four types of 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 and grand ward rounds) iv. Medication Reviewing v. Medication Reconciliation vi. Medication Counselling vii. Discharge Planning
Ward Pharmacy Activities
Tips to Achieve Pharmaceutical Care Goals Establish and maintain professional relationships with patients and other healthcare team members. 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 carry out the drug therapy plan. Review, monitor and modify therapeutic plan when necessary and in concert with the patient and healthcare team.
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3.0
Ward
Pharmacy
Activities
3.1
MEDICATION HISTORY TAKING
Medication history taking by pharmacists is essential for retrieving missing information with regard to prescription medications which the patient is currently on, information on past drug history as well as self-medication. This additional information can be an invaluable aid for pharmacists and other healthcare providers in assessing and determining 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 as supplements, over-the-counter (OTC) medicines and herbal preparations.
The Medication History Assessment Form (CP1) should be used as a guide for effective medicine history taking. The form should be kept with the patient's case notes to serve as a reference for other healthcare providers.
Important Points for Effective Medication History Taking 3.4 List all current medications, including self-prescribed medication supplements and herbal MEDICATION REVIEWING preparations with dosages and dates of commencement.
Medication orders should be reviewed for incomplete prescriptions, inappropriate drug unclear instructions, authenticity of the prescriber, administration to the present use, Write down the medication history of previous treatment that may be relevanterrors, appropriate drug storage and other issues related to patient's regimen. treatment and any reason for changes or alterations in the drug management in the ward to determine the pharmacotherapeutic appropriateness of each order for the individual patient. history of allergy or adverse drug reactions to any particular drug / food. Note 3.5 Assess compliance. MEDICATION RECONCILIATION
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 and potential pharmaceutical interventions are identified during these two activities. Pharmacists should play an active role in recognising these issues and documenting them into the case notes. If the PCI is significant to the patient's current medication plan, the issue should be highlighted to other healthcare providers during ward rounds or wherever necessary. Efficient case clerking and reviewing require skills to keep pharmacists focused on the active pharmaceutical care plans and interventions.
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Pharmacy
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3.0
Case clerking should be done for all new admissions as far as possible. The subsequent revision of the case is known as case reviewing. Recurrent admissions should be treated as new admissions, thus requiring new case clerking to be performed. All findings, suggestions and interventions performed pertaining to PCIs during case clerking / 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 daily basis until the patient is discharged. Patient's progress should be monitored by analysing objective and subjective parameters, updating current pharmaceutical care issues and intervening accordingly when necessary.
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
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-size drug reference e.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 be monitored

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 drug use, unclear instructions, authenticity of the prescriber, administration errors, appropriate drug storage and other issues related to patients drug management in the ward to determine the pharmacotherapeutic appropriateness of each order for the individual 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 the patient'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 of administration 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 correctly and consciously continued, discontinued or modified in a timely manner at each point in which the patient moves through the various levels of the health care continuum. It is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication order. Pharmacists should perform medication reconciliation at all points of 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 and discharge). 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 of patient'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 of understanding, inappropriate / inadequate instructions, complicated regimens or failure to fill a prescription. Ward pharmacists should conduct a patient-oriented interview, review medications, make appropriate recommendations to prescribers and / or patients themselves, and monitor patient outcome. Counselling is a professional relationship and activity which a pharmacist undertakes to enhance patients' knowledge on their pharmacotherapy and improve compliance to medications by giving professional advice, proper instructions and provision of aids where necessary. There are various ways to conduct medication counselling - individual (bedside or discharge) and group counselling. Bedside counselling is the counselling given to the patients in the ward. Discharge counselling is the counselling given to the patient to ensure that the patient/care-giver has a proper understanding of how to self-medicate upon discharge. Group counselling is counselling given to a group of patients with similar disease states. e.g. Warfarin group counselling, Diabetic group counselling, Cardiac Rehabilitation Program, etc. Pharmacists' thorough understanding of the patient's condition and disease are essential in order to get the patients involved in their drug therapy plan during medication counselling. The pharmacist should ensure that the patient is counselled on 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 carefully consider the psychosocial aspects of the medical conditions as well as the potential relation 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 a medication 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 similar medical problems / drug therapy, group counselling can be recommended.
STEP 2: PREPARE Study the patient medication profile, relevant medical history, social history and other related 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 upon discharge. Information provided during the counselling sessions should be documented in 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 referred using the Discharge Referral Note (CP4).
3.7 DISCHARGE PLANNING Ensuring continuity of care when patients are transferred from one hospital to another institution requires effective cooperation between fellow pharmacists and doctors to whom 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 medicines prescribed 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 management and the doctors in charge of the ward. When a patient is ready to be discharged, the doctor will write all the discharged medicines in the bed head ticket (BHT). The ward pharmacist may take on the responsibility for transcribing the medications which the patient is on into the prescription slip. All discharged prescriptions should be initialled by the pharmacists, counter checked by another pharmacist and signed by the attending physician. The transcribing of the discharge prescription will allow the doctor to save time during the process of discharging patients and will enable the patient to leave earlier. However, the doctor must be fully aware that the final responsibility for the prescription still lies with the doctor.
3.7.2
Preparation of Discharge Medications Discharge Summary (Appendix 8) comprise of list of patients being discharged on a particular day. It should be sent together with the discharged prescriptions to the inpatient / satellite pharmacist, who is responsible for
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Activities
3.0
screening and counterchecking for any errors. If any error is detected, the inpatient / satellite pharmacist should call the ward pharmacist to do the intervention. Discharge medication will be prepared by the inpatient / satellite pharmacist 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 have known if there is any balance medicines from the previous supply. If there is balance of medication and is found to be in a good condition, it should be reused as far as possible. Any excess or remaining previous medications that are discontinued in the ward should be returned to the pharmacy. The aim of this scheme is to optimize the use of current medications kept by patients and reduce wastage. 3.7.4 Bedside Dispensing and Discharge Counselling The objectives of this activity are: i. To speed up the patients discharge ii. To enhance patients 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 ward pharmacist. The ward pharmacist has to counsel the patient or family members on the medications prescribed, supply counselling aids (where necessary) and address any PCIs. Wards without a ward pharmacist can have the medication dispensed by the inpatient pharmacist, or any pharmacists on duty according to schedule.
29
4.0
Other
Activities
4.0
OTHER ACTIVITIES
Other activities in the Inpatient Pharmacy include the following: 4.1 4.2 4.3 4.4 4.5 4.6 Clinical Pharmacokinetic Service Drug Information Service Adverse Drug Reaction Monitoring and Reporting Medication Error Reporting Product Complaint Reporting Processing Requests for Non-Formulary Medications
4.1
Other Activities
CLINICAL PHARMACOKINETIC SERVICE
Clinical Pharmacokinetic Service ensures safe and efficacious dosage regimens through the application of pharmacokinetic / pharmacodynamic principles and the determination of drug serum concentrations. At the same time this service provides invaluable 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
30
Other
Activities
4.0
4.2
DRUG INFORMATION SERVICE
Pharmacists should serve as effective providers of drug information. All drug information requests from healthcare professionals / consumer / patients should be responded to immediately. By proper dissemination of drug information, the chances of medication errors can be prevented. This service can improve awareness and knowledge on health among the public in the quality use of medicine and pharmaceutical products. 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
Other Activities
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, or excessive 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 drug reactions (ADR).
31
4.0
Other
Activities
Process of Reporting by the Ward Pharmacist: The occurrence of untoward reactions found to be caused or suspected to be caused by a drug should be investigated and verified. The event should be highlighted to the prescriber or pharmacist. The adverse drug reaction should be verified and an Adverse Drug Reaction report should be completed by the doctor or pharmacist. The Drug Information Service (DIS) pharmacist should compile and submit the report to Malaysian Adverse Drug Reactions Advisory Committee (MADRAC). Reports may be submitted on-line or by posting the ADR form to MADRAC. Confidentiality of the reaction and patient information must be maintained at all times. The Malaysian Guidelines for Reporting and Monitoring of ADR can be obtained from the National Pharmaceutical Control Bureau NPCB) website. A description of the adverse reactions and the suspected drug should be recorded in the patient's bed head ticket / case note. The patient should be informed of the reaction and adequate advice given taking care to avoid legal implications. An allergy card should be given to the patient for documentation and as a form of alert for future drug use. The number of Adverse Drug Reaction events should be recorded in the Clinical Pharmacy Report Form (CP3). The data should be analysed to study trends in the occurrence of ADRs to identify drugs which are commonly implicated, changes in the frequency of occurrence and at risk groups. This information should be presented to the Drugs & Therapeutics Committee if deemed necessary.
Other Activities
4.4
MEDICATION ERROR REPORTING
A medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing, 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 expressing concern about a potential error or writing about an error that was discovered before 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
32
Other
Activities
4.0
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 ME report form (Appendix 12) to Pharmaceutical Services Division.
4.5
PRODUCT COMPLAINT REPORTING
Complaints on the quality, lack of efficacy, packaging, labelling, etc. of pharmaceutical products by other healthcare professionals should be looked into by the ward pharmacist. The reporter should fill in the Product Complaint Form (BPFK 418) and quarantine the related product. The DIS pharmacist should submit the form together with the sample to the Centre for Product Post Registration, NPCB for further action.
Each hospital / institution should have its own drug formulary adapted from the MOH drug formulary based on local needs and functions. The hospital formulary may not include all drugs in the MOH formulary. Newly-approved MOH drugs should follow the local hospital policy for inclusion into the hospital formulary. Formulary drugs should be the preferred choice of use at all times. Drugs not listed in the MOH formulary are called Non-MOH Formulary Medications and should not be prescribed before getting prior approval from the Director General of Health. However, when non-hospital formulary drugs are strongly indicated (in circumstances 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 nonMOH 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 justification by the respective Head of Department. All requests should be submitted to the Pharmaceutical Services Division, MOH for approval by the Director General of Health. The pharmacy department should monitor the non-MOH formulary drug usage once it is available in the hospital.
33
Other Activities
4.6
PROCESSING REQUESTS FOR NON FORMULARY MEDICATIONS
5.0
Documentation
5.0
DOCUMENTATION
Data collection through systematic documentation can be used for future planning and expansion of pharmacy services in the country. Drug information enquiries during the ward rounds should also be recorded in the Clinical Pharmacy Report Form. Areas of national importance such as cost savings and medication error reduction can be utilised to enhance a particular service. Please refer appendices for types of forms used 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 of medication, it is important to obtain this information prior to initiating treatment except in an emergency setting. A patient's treatment may be improved by an accurate drug history which highlights drug related causes for previous treatment failure, previous and potential adverse reactions, interactions, allergic, compliance, etc. The medication history should be filed together with patients medical progress notes (original copy) and for pharmacy record (carbonized copy) to facilitate easy reference during the patient's stay in hospital. Objectives To obtain a complete patient medication history within 24 hours of admission in order to improve the provision of pharmaceutical care. To design a pharmaceutical care plan with the doctor and patient.
Documentations
34
Documentation
5.0
This form is divided into 5 sections: A. Patient Biodata B. Reason For Admission C. Allergy and Adverse Drug Reaction D. Drug History E. 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 (past medical history, admission date/time, ward of admission, the medical doctor in charge, diagnosis, last discharge/review date, last encounter date at any hospital or clinic) from the Bed Head Ticket (BHT) or any of your hospital information retrieving system.
B.
Reason for Admission
C.
Obtain information from patient or care giver
Allergy and Adverse Drug Reaction History

D.
Drug History
Obtain information on prescribed and non-prescribed medications including use of traditional/complementary medicines from the patients or their caregiver Request the patient or care giver to bring prescribed and non-prescribed home medications, which the patient is currently on Check the physical condition, label and dosage of the drugs and record accordingly in the form Obtain the actual dose regimen taken by patient and compare with the dosing regimen on the label
35
Documentations
Obtain allergy and adverse drug reaction history by interviewing the patient or care giver and by reviewing past medical notes if available Record all confirmed, suspected and possible allergies and adverse drug reactions Record No Known Drug Allergy or NKDA if the patient has no history or unknown drug allergy and adverse drug reaction
5.0
Documentation
E.
Pharmacists Notes
Record patient's compliance status and their medications related problem Plan pharmaceutical care interventions to improve patients' drug therapy, compliance and understanding to treatment
5.2.2
Pharmacotherapy Review (CP2)
Introduction Continuous pharmaceutical monitoring is essential to achieve optimum outcome from the care plan which has been designed for the patient. Objectives
To obtain a complete patient medication history within 24 hours of admission 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
Documentations
Form Contents The form is divided into 5 main sections: Section 1 - Appendix 10a Section 2 - Appendix 10b & 10c Section 3 - Appendix 10d &10e Section 4 - Appendix 10f & 10g : Patient's Profile : Patient's Medication : Lab Investigations : Pharmaceutical Care Issues / Plan / Outcome : Discharge Medication
Section 5 - Appendix 10h
How to Complete Form CP2
Section 1 Obtain information from patient's BHT and Medication History Assessment Form (Form CP1). If required interview patients for further information.
36
Documentation
5.0
Section 2 Obtain information of medications which the patient has been prescribed / is on from the Medication Chart. Record complete drug regimen, date start and date stopped. Section 3 Obtain information from BHT or Hospital Laboratory Data Retrieving System. Record significant lab values related to the pharmaceutical care plan and treatment goal. Section 4 (Monitor patients progress) Record all ongoing pharmaceutical care issues, therapeutic plan, therapeutic assessment and follow-up required. Section 5 Record all discharged medication, and write the next appointment date.
5.2.3
Clinical Pharmacy Report Form (CP3)
Introduction Data collection is critical towards justifying for the future expansion of clinical pharmacy services and professional development and recognition in this country. Objectives
Documentations
To document pharmaceutical interventions for the purpose of Quality Assurance 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 pharmacist is away temporarily or off duty.
Forms Contents This form is divided into 4 sections.
37
5.0
Documentation
How to Complete Form CP3 Each form is to be filled on a daily or weekly basis depending on the practice in the ward in individual hospitals. A. Ward Pharmacy Activity
Routine round is the daily ward round conducted by the ward pharmacists 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 ward pharmacists participate with the consultants, specialists, medical officers and nursing staffs. Pharmacists round is the pharmacotherapy ward round involving the ward pharmacist with other fellow pharmacists. No. of cases clerked are the number of patients being clerked during new admissions. No. of cases reviewed are the clerked cases that are reviewed on the following days. No. of patients in the ward are the total numbers of patients in the ward on a particular day
B. Interventions / Requests Encountered
This refers to pharmaceutical interventions where there is an action that produces an effect or alteration in optimizing patient's pharmacotherapy. Pharmaceutical interventions are divided into four types namely Incomplete Prescription, Incorrect/ Inappropriate/ Inadequate Regimen, Inappropriate Prescription and Miscellaneous. Examples of TDM interventions are; identification of patients who require TDM, advice on appropriate sampling time, suggestions on dosage adjustment based on the TDM results. Examples of TPN interventions are; recommendation for TPN therapy, suggestion for appropriate TPN regimen, changes made to TPN therapy based on patient's response and outcome.
Documentations
C. Description of Requests / Intervention Encountered
This section summarises number of interventions done and number of request / information provided as in section B.
38
Documentation
5.0
D. Follow Up Required
This section is to transcribe any pharmaceutical care issues from Form CP2 during clerking and medication reviewing for further follow-up and clarification if required. This section is an important means of communication to ensure the continuity of pharmaceutical care 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 pharmacy discharge summary to be given to the primary care pharmacist or doctor. The patient should also be given the Discharge Referral Note for provision of further counselling and be informed that he / she is required to see the pharmacist in the follow-up facility. How to Complete Form CP4 The ward pharmacist identifies patients who require further monitoring for referral. The patient's diagnosis, medication list and discharge instructions in the patient's case notes should be reviewed. Pharmacists should fill in the Discharge Referral Note (CP4 - Appendix 10) to ensure further reviewing or counselling by the pharmacist in other healthcare setting takes place. All PCIs and action taken should be documented in the patient's case notes.
39
Documentations
6.0
References
6.0
REFERENCES
Dooley, M. J., Allen, K. M., Doecke, C. J., et al. 2003. A Prospective Multicentre Study of Pharmacist Initiated Changes to Drug Therapy and Patient 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. Petaling Jaya: 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: Concept and Manual. Petaling Jaya: Pharmaceutical Services Division, Ministry of Health. Pharmaceutical Services Division, Ministry of Health. 2009. Requirement for the Development of Pharmacy Facilities. Petaling Jaya: Pharmaceutical Services Division, Ministry of Health.
References
40
Appendices
7.0
7.0
APPENDICES
The forms used in Inpatient Pharmacy Practice are as follows:
MR - Medication Chart CMR - Cumulative Medication Record Advice Note Intervention Note Unit Dose Dispensing Checklist Referral Letter Drug Supply Registry Book Discharge Summary CP1 -Medication History Assessment Form CP2 -Pharmacotherapy Review CP3 -Clinical Pharmacy Record Form CP4 -Discharge Referral Note Report on Suspected Adverse Drug Reaction Medication Error (ME) Report Form Product Complaint Form
Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Appendix 10 Appendix 11 Appendix 12 Appendix 13 Appendix 14 Appendix 15
41
Appendices
Appendices
Appendices
42
Appendix 1
MEDICATION CHART NAME : ................................................... I/C : ........................................................ R/N : ................................................... AGE WEIGHT : : ..
DIAGNOSIS : .. ALLERGY
WARD / BED : ........................
MEDICATION RECORD Name/Ward/Bed DRUG Dose Route Date Prescriber's signature & stamp Freq Duration
Date Time
Name/ Ward/ Bed DRUG Dose Route
Date Prescriber's signature & stamp Freq Duration Date Prescriber's signature & stamp
Freq
Duration Date
Prescriber's signature & stamp Freq Duration Date Prescriber's signature & stamp Route Freq Duration
Appendices
Name/ Ward/ Bed DRUG
Dose
Note : original prescription (white) carbonised copy (yellow)
43
Appendix 2
CUMULATIVE MEDICATION RECORD PATIENT PARTICULAR NAME : ................................................... I/C : ........................................................ R/N : ................................................... AGE WEIGHT : : ..
DIAGNOSIS : .. ALLERGY
WARD / BED : .......................
MEDICATION RECORD
Date Amount Date Amount Date Amount
Note
Appendices
44
Appendix 3
Inpatient Pharmacy Hospital ________________ ADVICE NOTE

Date :___________ Time :_________ Patient I.C. No. R/N Ward Age : _________________________________________________________________________ : _____________________________ : ______________________ : _____________ : ___________ years Bed No. Weight : _______________ : ________ kg
Diagnosis: _____________________________________________________ Dear Pharmacy staff, With regards to this patient, we wish to advice the following: New admission Discharged / Deceased Transferred from Ward _______ to Ward _______ Bed no. ________ Bed no. ________
Medication stopped / changed ____________________________________________ ______________________________________________________________________ Other ___________________________________________________________________ ______________________________________________________________________
For pharmacy use only:
__________________________ Sign & Stamp

Appendices
45
Appendix 4
Inpatient Pharmacy Hospital ________________ 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
46
Appendix 5 Unit Dose Dispensing Checklist

Inpatient Pharmacy Service, Hospital ................................ WARD: Month
Date
YEAR: JANUARY
Dispensed: Received by: Charted: No. Errors: Checked: Dispensed:
SATELLITE: FEBRUARY
Checked: Dispensed: Received by: Charted: No. Errors: Checked:
MARCH
Received by: Charted: No. Errors:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 26 27 28 29 30
Appendices
25
47
Appendix 6
KEMENTERIAN KESIHATAN MALAYSIA SURAT RUJUKAN HOSPITAL ______________________ Tarikh Temujanji:
Rujukan mestilah kepada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital Kepada Tarikh : : : Jabatan / Unit Masa Umur Jantina : : : No. Rujukan Kami : : : :
Nama Pesakit No.K/P :
No. Rujukan Tuan
History & Physical Findings
Results of Investigations :
Diagnosis Treatment
: :
Purpose of Referral
Daripada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital Nama : Tandatangan Tel : :
Hospital / Jabatan / Unit

Appendices
Nota : Sila isi borang dalam 3 salinan Salinan Pertama Salinan Kedua : Diberi kepada pesakit (untuk diberi kepada doktor di institusi yang dirujuk) : Diberi kepada Pegawai Farmasi hospital merujuk (untuk difaks/ pos kepada Pegawai Farmasi hospital / klinik dirujuk) Salinan Ketiga : Disimpan dalam fail pesakit
48
Appendix 7
BUKU DAFTAR PEMBEKALAN UBAT
(Drug Supply Registry Book)
BAGI PESAKIT YANG DIRUJUK BAGI MENERUSKAN RAWATAN KE FASILITI KESIHATAN LAIN Hospital / Klinik Kesihatan / Negeri : ____________________________ Tahun : _______________
Tarikh
No Rujukan Borang
Sumber Rujukan (Hospital asal yang merujuk)
Bekalan Ubat Kategori A serta ubatubat yang tiada dalam formulari (Tempoh Sebulan) Nama dan Kuantiti kekuatan dibekal ubat Kos (RM)
Tempoh pesakit dirujuk
Jumlah Kos (RM)
Jumlah
49
Appendices
Appendix 8
Inpatient Pharmacy Hospital ________________ DISCHARGE SUMMARY
Dear Pharmacy staff, We wish to advice that the following patients have been discharged: Bed No. Reg. No. Patients Name
WARD: __________
For pharmacy use only:
___________________ (Staff Nurses Name) Date : _____________
Appendices
50
Appendix 9a
51
Appendices
Appendix 9b
Appendices
52
Appendix 10a
PHARMACOTHERAPY REVIEW PHARMACOTHERAPY REVIEW
CP2
Pharmacy Department, Hospital ______________ Ref. no: ALLERGY
Name : Race : M / C / I / Others
MRN : Ht/Wt :
Age : DOA :
Gender : M / F Ward/Bed :
Chief Complaint:
History of Present Illness:
Past Medical History:
Review of system: BP: PR: mmHg p/min RR: T:

O
b/min C
Social/Family History:
Smoking Alcohol Drug Abuse Pregnant
Past Medication History:
Compliance Evaluation:
Diagnosis/Surgical Procedure:
Sign & Stamp:
Pind 1//10
53
Appendices
Appendix 10b
WARD MEDICATION DRUG / REGIMEN DATE START DATE STOP
54
ELECTROLYTE THERAPY
CARDIOVASCULAR
Appendices
ANTIBIOTIC
Appendix 10c
WARD MEDICATION DRUG / REGIMEN DATE START DATE STOP
OTHERS
DIABETES
DATE
INFUSION CHART
Dopa Dobu Norad Mida Morp Insulin INPUT OUTPUT BALANCE

Appendices
Mida/Morp
I/O CHART
55
Appendix 10d
TWBC Hb RBC HCT Platlet Urea Na K Cl Ca Mg PO4SCr ClCr Albumin T.Bilirubin T.Protein ALP ALT PT APTT INR CK LDH AAT pH pCO2 pO 2 HCO3 O2 sat RBS
Day & Date N.Range 4-11 x10/L 11.5-16.5 g/100mL 4.5-6.3x106 0.4/0.37-0.52/0.48 150-400 x10/L 1.7-8.3 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 96-106 mmol/L 2.1-2.6 mmol/L 0.7-1.3 mmol/L 0.8-1.45 mmol/L 64-122 umol/L 105-150 mL/min 35 <20 66 53 <32 50 g/L umol/L 87 g/L 141 u/L u/L
Liver profile
BUSE / Renal Profile
FBC
10-13.5 sec 26 - 42 sec <1.5 24 - 195 u/l 0 - 248 u/l <37 7.35-7.45 35-45mmHg 72-100mmHg 22-29mmol/L 90-95% < 11 mmol/L
Others
ABG
Cardiac enzymes
Coag. profile
BP TEMP RR PR Date
Vital signs
56
C&S
Appendices
12 - 18 b/min 60 - 100 p/min Date (sampling) Sources/sample M/organism Sensitivity Resistant
Appendix 10e
10
11
12
13
14
15
16
17
18
19
20
Date T. Chol C-TG C-HDL C-LDL <5.7 mmol/L <1.7 mmol/L >1.7mmol/L <3.9 mmol/L
Lipid
57
Appendices
Appendix 10f
DATE
PHARMACEUTICAL CARE ISSUES
PHARMACIST RECOMMENDATION
OUTCOME
Appendices
58
Appendix 10g
DATE
PHARMACEUTICAL CARE ISSUES
PHARMACIST RECOMMENDATION
OUTCOME
59
Appendices
Appendix 10h
DISCHARGE MEDICATION
Appendices
NEXT TCA:
60
Appendix 11a CLINICAL PHARMACY REPORT FORM

Pharmacy Department, Hospital .. A: WARD PHARMACY ACTIVITY Date : Ward : Task : Full Time / Part Time Physician(s) :
CP3
Routine Rounds Grand Rounds Pharmacist Rounds 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 interventions
(1) Incomplete Prescription
Number of interventions accepted
Request / Information Provided
Number Total
Patient data Drug Dose Frequency Duration Drs Stamp & Sign
Adverse Drug Reaction Drug Toxicity Drug Dosage Therapeutic Efficacy Drug Indication Drug Interaction Pharmacokinetic TPN General Product Information Pharmaceutical Availability Pharmaceutical Compatibility Pharmaceutical Identification
(2) Incorrect/ Dose Inappropriate/ Inadequate Frequency Duration Regimen (3) Inappropriate Contraindication Prescription Drug Interaction Incompatibility Unclear Handwriting Authenticity of (4) Miscellaneous Prescription/ Prescriber Drug Administration Error Suggest For Vital Signs Monitoring/ Laboratory Investigation TDM TPN Polypharmacy
Drug
TOTAL INFORMATION PROVIDED COUNSELLING Bedside Counselling Group Counselling GRAND TOTAL
Appendices
Number Total No. Of Of Sessions Patients
Discharge Counselling
TOTAL INTERVENTIONS
61
Appendix 11b
C: DESCRIPTION OF REQUESTS / INTERVENTIONS ENCOUNTERED
D: FOLLOW-UP REQUIRED No FOLLOW-UP CHECKLIST SIGN
Appendices
..
Pharmacist Sign & Stamp Date:
Pin. 1/10
62
Appendix 12
DISCHARGE REFERRAL NOTE
63
Appendices
Appendix 13
Appendices
64
Appendix 14
65
Appendices
Appendix 15
BORANG LAPORAN ADUAN PRODUK YANG BERDAFTAR DENGAN PIHAK BERKUASA KAWALAN DADAH
Product Complaint Form for Products Registered with the Drug Control Authority
SILA KEMUKAKAN SAMPEL ADUAN BERSAMA DENGAN BORANG INI

Please send complaint samples with this form
i. MAKLUMAT PRODUK
Particulars of Product
NAMA PRODUK:
Name of Product
NO. PENDAFTARAN PBKD/MAL:

Registration Number
NO. KELOMPOK:
Batch Number
TARIKH DIKILANGKAN:
Manufacturing Date
TARIKH LUPUT:
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 efficacy
Bagi 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:
Name
JAWATAN/PEKERJAAN:
Designation/Occupation
ALAMAT LENGKAP TEMPAT KERJA:

Address
Appendices
TELEFON:
Telephone
FAX:
Fax
TANDATANGAN:
Signature
TARIKH:
Date SEKSYEN SURVEILANS & ADUAN PRODUK PUSAT PASCA PENDAFTARAN PRODUK BIRO PENGAWALAN FARMASEUTIKAL KEBANGSAAN KEMENTERIAN KESIHATAN MALAYSIA JALAN UNIVERSITI, PETI SURAT 319 46730 PETALING JAYA Fax: 603-79567151
Sila hantar kepada:

Please send to:
66
8.0
1. 2. 3. 4. 5.
GLOSSARY
Dose regimen - A complete information on name of drug, mode of administration, dosage, frequency and duration Compliance aid - Any device such as pillbox, pamphlet or timetable guide that helps to improve the patient's compliance to medication Pharmaceutical Care issue (PCI) - Any problems related to patients' diseases and drug treatment conditions Single Ward - Only one individual ward Counseling - A professional relationship and activity through which a pharmacist endeavours to educate patients on their pharmacotherapy and enhance compliance to medications by giving professional advice, opinion and instructions. Bedside counseling - Counseling given to patient who is in the ward Discharge counseling - Counseling given to patient upon discharge Group counselling - Counseling given to a group of patient who has similarity in disease state QAP - Quality assurance programme PF - Pengurusan Farmasi is an indicator for monitoring the workload and performance of the activities in the pharmacy services. Routine round - Daily ward round between the ward pharmacists, medical officer with or without the specialist or consultant. Grand round - Scheduled departmental round participated by the ward pharmacists with the consultants, specialist, medical officer and nursing staff. Pharmacists round - Pharmacotherapy ward round involving the ward pharmacist with other fellow pharmacists. No. of cases clerked - Cases clerked for the first time during the current admission No. of cases reviewed - Clerked cases that are reviewed on the following days Chief complaints (CC) - Main complaints made by the patients during admission. It should be documented as layman term
Glossary
6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
67
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 previous admissions to hospital and specialist referrals 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 Family history (FHx)
19.
20.
Relevant familial illness especially premature deaths of parents or siblings

21. 22. 23. 24. 25. 26. FUKKM - Formulasi Ubat, Kementerian Kesihatan Malaysia is a list of a drug formulary under Ministry of Health Health Facility - Hospital, Health Clinic and Health Institution under Ministry of Health Second Copy - a referral letter that is used to refer patient from one facility to another LP form - Local Purchase Form DOA - Date of Admission TDM - Therapeutic Drug Monitoring
Glossary
68

Guidelines For Inpatient Pharmacy Practice

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PHARMACEUTICAL SERVICES PHARMACEUTICAL SERVICES DIVISION MINISTRY HEALTH MALA MINISTRY OF HEALTH MALAYSIA

GUIDELINES FOR INPATIENT PHARMAC Y PRACTICE

MINISTRY OF HEALTH MALAYSIA

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

Director Pharmacy Practice and Development Division Ministry Of Health Malaysia

3.0 Ward Pharmacy Activities

4.0 Other Activities

5.0 Documentations 6.0 Reference 7.0 Appendices 8.0 Glossary

GUIDELINES FOR INPATIENT PHARMAC Y INPA PHARMAC PRACTICE PRACTICE

Inpatient Pharmacy Services

INPATIENT PHARMACY SERVICES

DRUG DISTRIBUTION ACTIVITIES

Drug Distribution Activities

UNIT DOSE SYSTEM

Drug Distribution Activities

Prescriber's signature & stamp

AMOUNT DATE 2X4

Drug Distribution Activities

12/10/09 1 x 5ml atau 1 x 30g

TELAH DIBEKAL PADA

Drug Distribution Activities

Example 2: Tab. Chlorpheniramine 4mg TDS & PRN DATE

FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS

AFTER OFFICE HOURS SUPPLY

SUPPLY OF PSYCHOTROPIC MEDICINES

SUPPLIES FOR DISCHARGED PATIENTS

To ensure preparedness of medications at the referred facility To ensure continuity of treatment

WARD / UNIT INSPECTION

Drug Distribution Activities

Criteria for Good Drug Distribution Service

WARD PHARMACY ACTIVITIES

MEDICATION HISTORY TAKING

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

Ward Pharmacy Activities

Use the following easy steps for effective medication counselling.

STEP 1: PLAN Prioritise potential patient for counselling based on:

Complexity of therapeutic plan

Ward Pharmacy Activities

CLINICAL PHARMACOKINETIC SERVICE

DRUG INFORMATION SERVICE

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

ADVERSE DRUG REACTION MONITORING AND REPORTING

MEDICATION ERROR REPORTING

PRODUCT COMPLAINT REPORTING

PROCESSING REQUESTS FOR NON FORMULARY MEDICATIONS

UNIT DOSE SYSTEM (UDS) FORMS

WARD PHARMACY FORMS 5.2.1 Medication History Assessment Form (CP1)

Reason for Admission

Obtain information from patient or care giver

Allergy and Adverse Drug Reaction History

Pharmacotherapy Review (CP2)

Section 5 - Appendix 10h

How to Complete Form CP2

Clinical Pharmacy Report Form (CP3)

Forms Contents This form is divided into 4 sections.

B. Interventions / Requests Encountered

C. Description of Requests / Intervention Encountered

Discharged Referral Note (CP4)

The forms used in Inpatient Pharmacy Practice are as follows:

WARD / BED : ........................

Name/ Ward/ Bed DRUG Dose Route

Name/ Ward/ Bed DRUG Dose Route

Medication stopped / changed ________ Other _ ______________________________________

_______ (Staff Nurses Name) Date : _