Get Adverse Drug Reaction Form - Kaiser Permanente - Community ... - Providers Kaiserpermanente 2020-2025

Filling out the Adverse Drug Reaction Form is essential for documenting undesirable responses to medications that require medical attention. This guide will take you through the process step-by-step to ensure you accurately complete the form.

Follow the steps to effectively complete the Adverse Drug Reaction Form

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the patient's name and medical record number (M.R.N.) in the designated fields.
3. List the drug(s) suspected to be involved by filling in the name, strength, total daily dose, route, start date, and reason for use in the appropriate sections.
4. Describe the reaction experienced by the patient in the provided description area. Be thorough to ensure clarity.
5. Record the date of onset of the reaction and the name of the prescribing physician in the specified fields.
6. Classify the patient's clinical outcome by checking one of the provided categories (C through H) to indicate the severity of harm.
7. If there was any treatment given for the reaction, describe it in the provided section.
8. Reflect on what could have been done differently to prevent the reaction and provide this information in the designated area.
9. Indicate whether the Vaccine Adverse Event Report and FDA Medwatch have been completed by checking the appropriate boxes.
10. Note if the patient has been informed of the reaction by selecting the correct option.
11. Fill in the reporter’s name, date, and facility/department at the bottom section.
12. Ensure the physician signs and dates the form and fills in their facility/department.
13. Review the completed form for accuracy, then fax the completed document to Kaiser Permanente Pharmacy Administration at 1-216-749-8426.

Complete your Adverse Drug Reaction Form online today.