Reporting and documentation of ADR/ME and TDM

Ms Chao continues to give detailed examples of clinical pharmacy services (CPS) TVGH provides, including reporting and documenting adverse drug effects (ADR) and medical error (ME), and therapeutic drug monitoring (TDM).

Document and report ADR and ME:

This is supported by computerized systems such as the Intelligent Pharmacists Service System (iPASS) which provide information in the form of a pre-medical round sheet. iPASS also help pharmacist document records. At TVGH the default format of pharmacy notes is the SOAP format.

• S stands for Subjective, a summary of patient information, chief complaint, diagnosis, and past or current medication history.
• O stands for Objective, which includes records of the vital signs, related exam results or lab data, etc.
• A stands for Assessment, identification of the clinical problem, usually the drug-related problem.
• P stands for Plan, suggested adjustments, or interventions. The outcome (whether physicians accepted the suggestions and patients’ conditions) is also recorded here.

We will see a couple of examples in SOAP format.

Next, reporting system. It consists of consulting service system, online ADR reporting system, and a medication error reporting system. Consulting service system allows pharmacists to document any drug information-related inquiry from ambulatory patients, discharge patients, or healthcare professionals. Medication error and ADR reporting systems can help pharmacists to maintain quality and medication safety.

Share and learn:

• How do you usually record ADRs and MEs? Is there a uniform format at the hospital you work at?