CHART SMART: Documenting an adverse drug reaction

October 2005 
Volume 35  Number 10
Pages 22 - 22
  PDF Version Available!


PROPERLY CHARTING a patient's adverse drug reaction (ADR) can protect him from further harm and shield you and your facility from legal problems. But documenting ADRs has wider implications too: Because a significant part of the evaluation for any drug's long-term safety occurs after it's on the market, serious ADRs should be reported to the Food and Drug Administration's (FDA's) MedWatch program.

If you suspect an ADR, care for the patient, then notify the prescriber. If the ADR is serious, stay with the patient and have a colleague notify the prescriber. Document the patient's clinical condition, your interventions, and the patient's response. When the patient is stable, inform your supervisor, pharmacist, and risk manager if the ADR was serious. Depending on facility and state health department policies, you may also need to notify the patient or family. Fill out an incident report and internal ADR report, which should contain all the information ...

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