Intervention: (Only Select One Per Entry in Rxpreceptor)

Acute Care Patient Interventions

Field Encounters

Age of Patient: Years

Gender: Male Female

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

ADR identified or intervention / Medication recommendation
Allergy prevented / Medication reconciliation
Antibiotic recommendation / Medication/disease counseling
Blood glucose management / Nutrition (enteral) evaluation
CPR/Code attended / Nutrition (TPN) evaluation
Dose adjustment or recommendation / Pharmacokinetic evaluation
Drug Information provided / Pharmacy calculation
Drug-food interaction / Pharmacy consultation
Drug-drug interaction / Stress ulcer prophylaxis
DVT prophylaxis / Therapeutic drug monitoring
Electrolyte replacement recommendation / Therapeutic duplication avoided
IV to PO recommendation / Therapeutic substitution
Lab recommendation / Vaccine administration
Medication history / Vaccine recommendation
Medication management / Other
Comments:

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Acute Care Patient Interventions

Field Encounters

Age of Patient: Years

Gender: Male Female

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Acute Care Patient Interventions

Field Encounters

Age of Patient: Years

Gender: Male Female

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown

Acute Care Patient Interventions

Field Encounters

Age of Patient: Years

Gender: Male Female

Ethnicity of Patient:

White / African American / Hispanic / Asian
American Indian / Native Hawaiian / Two or more races / Other

Date:

Medication 1:

Medication 2:

Intervention: (only select one per entry in RXpreceptor)

Discussed intervention with: (able to select multiple)

Nurse / Other professional / Patient/caregiver / Physician
Preceptor

Recommendation status:

Accepted / Not accepted / Not applicable / unknown