FS1 Extended Interventions Proforma

The purpose of an extended intervention is to show some contributions to care that go a bit deeper (or ‘extend’ beyond) those you might use for a SIP. You do NOT need to make lots of interventions. However, the interventions/contributions you do make must show the application of evidence to guide decisions at least once, e.g. from local/national guidelines. You should also show practice beyond basic screening or meds reconciliation tasks e.g. MDT working, balancing lots of problems together, managing multiple morbidities, tackling transfer of care issues etc.

Patient initials / Age / Sex / Weight / Clinical area or context for intervention:
PC /details of acute problems/reason for your involvement with the patient / PMH
Relevant social history
Relevant test results, physical assessments, scoring tools, objective measures etc
Only include anything relevant to the drug treatment and interventions. You must justify why each result is relevant here and interpret what it means for this patient.
DH / Allergy status:
1 / 13
2 / 14
3 / 15
4 / 16
5 / 17
6 / 18
7 / 19
8 / 20
9 / 21
10 / 22
11 / 23
12 / 24
Overview of the case
For hospital in-patients, summarise the chronology of events and any changes over the duration. For non-acute cases, summarise the case background, how you have been involved and what has happened. Give as much detail as possible to provide context for your case and the interventions in the next section.
Interventions Log
(Copy and paste a new box for each intervention made)
Identified problem/cause of problem:
Outline details of the pharmaceutical issue / Advice, recommendations and actions:
In this column, show how evidence has guided your decisions and recommendations / Outcomes and any monitoring/ follow-up:
Include any relevant monitoring and follow-up for you or the MDT
Identified problem/cause of problem: / Advice, recommendations and actions: / Outcomes and any monitoring/ follow-up:
Identified problem/cause of problem: / Advice, recommendations and actions: / Outcomes and any monitoring/ follow-up:
Identified problem/cause of problem: / Advice, recommendations and actions: / Outcomes and any monitoring/ follow-up:
Local and national guidelines references:
You need to show how these have influenced your decision-making in the interventions log above
Personal reflections on significant events:
What have you learnt that might change your practice as a pharmacist? What was interesting/ surprising/challenging and why? What learning gaps do you need to address now?
Author / Elaine Sharp / Issue Date / Aug 2016 / Version / 2
Reviewer / HEI Academic Team / Review Date / Jul 2018 / Supersedes / 1
Copyright © 2011. Kent, Surrey & Sussex Foundation Pharmacists Programme