Pharmacy Deployment Forms

1. Pharmacy Deployment Forms Lessons Learned from Hurricanes Katrina, Rita, and Wilma - Lack of forms to keep track of patient records, drug supplies, and credentialing information in clinics or federal medical stations (FMSs) Need for standardized pharmacy forms Developed by members of PharmPAC Public Health Pharmacy Workgroup and PHS RDF team (Pharmacy Branches)

2. Pharmacy Deployment Forms Continual improvement � based on field testing or actual use (Deployment Forms Workgroup will meet on a quarterly basis to make updates) PHS Forms � have been approved by the PharmPAC and will be posted on the PharmPAC website soon Not intended to replace other forms available during a deployment mission, but available as needed based on the needs of the mission and pharmacy

3. Pharmacy Deployment Forms Administrative Forms PHS FORM ADM-001 RPh record and credentialing PHS FORM ADM-002 Important Contacts (federal, state, local) PHS FORM ADM-003 Prescriber record and credentialing PHS FORM ADM-004 Controlled Substance (CII) Inventory Log PHS FORM ADM-005 Controlled Substances (CIII-CV) Inventory Log PHS FORM ADM-006 Controlled Substance Medication Administration Log PHS FORM ADM-007 Prescription Forms Description of each form PHS FORM ADM-001 RPh record and credentialing - daily record to verify credentials of all RPh�s that are authorized to work in the pharmacy PHS FORM ADM-002 Important Contacts � for safety (PHS team safety officer) and for obtaining drugs: federal contacts (SNS, DEA, SOC), state (State Health Depts., State Boards of Pharmacy) and local (wholesalers, hospitals, retail & community pharmacies); useful to have this info to pass on to the next team that augments the mission PHS FORM ADM-003 Prescriber record and credentialing � daily record to verify credentials of MDs for prescribing, in addition, prescribing of controlled substances. PHS FORM ADM-004 Controlled Substance (CII) Inventory Log PHS FORM ADM-005 Controlled Substances (CIII-CV) Inventory Log PHS FORM ADM-006 Controlled Substance Medication Administration Log � used to keep track of when the controlled medication was dispensed to the patient (in-patient). PHS FORM ADM-007 Prescription Forms � Blank Prescription Forms, to have a hard copy of each medication order, also can be used if the site is issuing prescriptions for subsequent fills after the patients are releasedDescription of each form PHS FORM ADM-001 RPh record and credentialing - daily record to verify credentials of all RPh�s that are authorized to work in the pharmacy PHS FORM ADM-002 Important Contacts � for safety (PHS team safety officer) and for obtaining drugs: federal contacts (SNS, DEA, SOC), state (State Health Depts., State Boards of Pharmacy) and local (wholesalers, hospitals, retail & community pharmacies); useful to have this info to pass on to the next team that augments the mission PHS FORM ADM-003 Prescriber record and credentialing � daily record to verify credentials of MDs for prescribing, in addition, prescribing of controlled substances. PHS FORM ADM-004 Controlled Substance (CII) Inventory Log PHS FORM ADM-005 Controlled Substances (CIII-CV) Inventory Log PHS FORM ADM-006 Controlled Substance Medication Administration Log � used to keep track of when the controlled medication was dispensed to the patient (in-patient). PHS FORM ADM-007 Prescription Forms � Blank Prescription Forms, to have a hard copy of each medication order, also can be used if the site is issuing prescriptions for subsequent fills after the patients are released

4. PHS FORM ADM-002

5. PHS FORM ADM-007

6. Pharmacy Deployment Forms Description of forms: PHS FORM ADM-008 Immunization Log � may be use for mass immunization PHS FORM ADM-009 Refrigerator/Freezer Temperature Log - to ensure drug products that require refrigeration or colder, are maintained at appropriate temperatures PHS FORM ADM-010 Room Temperature Log � to ensure that drug products are stored under appropriate conditions Clinical Form PHS FORM CLN-001 Medication Reconciliation & Order Form � intake form to gather patient info on medication use and history, family medical history, OTC use, herbal & supp use Description of forms: PHS FORM ADM-008 Immunization Log � may be use for mass immunization PHS FORM ADM-009 Refrigerator/Freezer Temperature Log - to ensure drug products that require refrigeration or colder, are maintained at appropriate temperatures PHS FORM ADM-010 Room Temperature Log � to ensure that drug products are stored under appropriate conditions Clinical Form PHS FORM CLN-001 Medication Reconciliation & Order Form � intake form to gather patient info on medication use and history, family medical history, OTC use, herbal & supp use

7. PHS FORM CLN-001 Forms have not been finalized yet. But soon�.Forms have not been finalized yet. But soon�.

8. Pharmacy Deployment Forms Description of forms: PHS FORM ADM-008 Immunization Log � may be use for mass immunization PHS FORM ADM-009 Refrigerator/Freezer Temperature Log - to ensure drug products that require refrigeration or colder, are maintained at appropriate temperatures PHS FORM ADM-010 Room Temperature Log � to ensure that drug products are stored under appropriate conditions Clinical Form PHS FORM CLN-001 Medication Reconciliation & Order Form � intake form to gather patient info on medication use and history, family medical history, OTC use, herbal & supp use Description of forms: PHS FORM ADM-008 Immunization Log � may be use for mass immunization PHS FORM ADM-009 Refrigerator/Freezer Temperature Log - to ensure drug products that require refrigeration or colder, are maintained at appropriate temperatures PHS FORM ADM-010 Room Temperature Log � to ensure that drug products are stored under appropriate conditions Clinical Form PHS FORM CLN-001 Medication Reconciliation & Order Form � intake form to gather patient info on medication use and history, family medical history, OTC use, herbal & supp use