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Therapeutic ineffectiveness
Therapeutic ineffectiveness
Therapeutic Ineffectiveness Report Form
Therapeutic Ineffectiveness Report Form
A Therapeutic Ineffectiveness Report Form is to be used to document and report situations where a medication does not produce the expected or desired therapeutic effect in a patient. Essentially, it is a report that indicates our products failed to work as intended, even when used correctly
Patient Information
Initials or ID
Age
Please enter a number from
1
to
150
.
Weight(Kg)
Please enter a number from
1
to
200
.
Height(cm)
Please enter a number from
1
to
250
.
Gender
Select
Other
Female
Male
Medical Record Number (if applicable)
Suspected Medication Information
Brand Name
Strength
Dosage
Route of Administration
Select
Oral
IV
IM
Subcutaneous
Topical
Other
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Indication for use
Description of Therapeutic Ineffectiveness
Date Treatment Started
MM slash DD slash YYYY
Duration of Therapy
Expected Outcome of Therapy
Actual Outcome (describe the lack of effectiveness)
Relevant Clinical Tests or Observations
Compliance Information
Was the medication taken as prescribed?
Select
Yes
No
if No, explain any deviations:
Concomitant Medications (if any)
Name, Dosage, Route, Start Date and End Date
Relevant Medical History (e.g., chronic conditions, allergies):
Other Possible Factors Affecting Effectiveness (e.g., diet, environment, concurrent illnesses):
Outcome of Therapeutic Ineffectiveness
Select
Therapy Discontinued
Therapy Switched
Continued with No Changes
Other
Other
Further Actions Taken
Reporter Information
Name
Position (e.g., doctor, pharmacist, patient)
Phone
Email
Assessment of Causality
Select
Likely Related
Unlikely Related
Unknown
Date of report
MM slash DD slash YYYY
Consent to follow up
Select
Yes
No
