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TDM Request Form

This document is a therapeutic drug monitoring request form containing a patient's profile, clinical summary, diagnosis, lab results, current medications, and sections for a doctor's signature authorizing the request and a pharmacist's assessment. The form provides essential information about a patient to monitor drug levels and determine appropriate dosing.

Uploaded by

Muhammad Iqbal
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We take content rights seriously. If you suspect this is your content, claim it here.
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634 views3 pages

TDM Request Form

This document is a therapeutic drug monitoring request form containing a patient's profile, clinical summary, diagnosis, lab results, current medications, and sections for a doctor's signature authorizing the request and a pharmacist's assessment. The form provides essential information about a patient to monitor drug levels and determine appropriate dosing.

Uploaded by

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