Guidelines Inpatient Pharmacy Practice

PHARMA
CEUTICAL SER
VICES DIVISION
PHARMACEUTICAL
SERVICES
MINISTR
Y OF HEAL
TH MAL
AYSIA
MINISTRY
HEALTH
MALA
GUIDELINES FOR
INPATIENT
PHARMAC Y
PRACTICE
Guidelines for Inpatient Pharmacy Practice : Pharmaceutical Services Division Ministry of Health Malaysia
MINISTRY OF HEALTH MALAYSIA
First Print, 2010

Pharmaceutical Services Division,
Ministry of Health, Malaysia.
ALL RIGHTS RESERVED

No part of this publication may be reproduced, stored
or transmitted in any form or by any means whether
electronic, mechanical, photocopying, tape recording or others without written permission from the
Senior Director of Pharmaceutical Services, Ministry of Health, Malaysia.
Perpustakaan Negara Malaysia

Guidelines for Inpatient Pharmacy Practice, Ministry
of Health Malaysia.
ISBN 978-967-5570-12-4
PREFACE
Director
Pharmacy Practice and Development Division
Ministry Of Health Malaysia
Pharmacy Practice and Development Division has been evolving and this is evidenced
through years of excellence in performance. Primarily focussed on patient safety, we
are responsible for the optimisation of drug therapy and prevention of medication errors.
Throughout the expansion of services, Pharmacy Practice and Development
Division has introduced standardisation of procedures towards assisting proper
management of Drug Distribution and Ward Pharmacy activities. This Guidelines for
Inpatient Pharmacy Practice will serve as a tool for all to work conscientiously for the
benefit of patients.
This guideline focuses on good management of drug distribution describes work
flows of the Inpatient Pharmacy processes and explanation of the necessary
documents involved. It is hoped that the guidelines are able to steer good
management practice in conducive environments towards fulfilment of customers'
needs.
I would like to convey my gratitude to the Clinical & Technical Pharmacy Working
Committee in the success of producing this guideline. Also, a special thanks to all
parties that contributed during all stages of development and publication of this
guideline.
Thank you
Hasnah binti Ismail

Director,
Pharmacy Practice and Development Division,
Ministry of Health Malaysia.
Table of Contents
Page
Preface
Table of Contents
Editorial Board
1.0 Inpatient Pharmacy Services
2.0 Drug Distribution Activities

2.1
2.2
2.3
2.4
2.5
2.6
2.7
Unit Dose System

Floor Stock / Emergency Trolley Medications
After Office Hours Supply
Supply of Psychotropic Medicines
Supplies for Discharged Patients
Handling Referral Letter (Second Copy) and
Supply of Medications for Patients being referred
to Health Facilities
Ward / Unit Medication Inspection
3.0 Ward Pharmacy Activities

3.1
3.2
3.3
3.4
3.5
3.6
3.7
Medication History Taking

Case Clerking
Pharmacotherapy Rounds
Medication Review
Medication Reconciliation
Medication Counselling
Discharge Planning
10
10
16
17
17
17
18
19
21
22
22
23
25
26
24
28
4.0 Other Activities

4.1
4.2
4.3
4.4
4.5
4.6
Clinical Pharmacokinetic Service

Drug Information Service
Adverse Drug Reaction Monitoring and Reporting
Medication Error Reporting
Product Complaint Reporting
Processing Request for Non-Formulary Medications
30
31
31
32
33
33
5.0 Documentations
34
6.0 Reference
40
7.0 Appendices
41
8.0 Glossary
67
Editorial Board
Advisors
Eisah A Rahman
Senior Director of Pharmaceutical Services,
Ministry of Health Malaysia
Hasnah Ismail
Director of Pharmacy Practice and Development
Pharmaceutical Services Divison, MOH
Editors
Abida Haq Syed M. Haq
Deputy Director
Pharmaceutical Services Division, MOH
Ainul Salhani Abdul Rahman
Principal Assistant Director
Rabi'ah Mamat
Principal Assistant Director
Phuar Hsiao Ling
Senior Assistant Director
GUIDELINES FOR
INP
ATIENT PHARMA
CY
INPA
PHARMAC
PRACTICE
PRA
CTICE
1.0
Pharmacy
Services
1.0
INPATIENT PHARMACY SERVICES
Pharmaceutical care is an area in the health care system which has yet to be fully
developed in Malaysia although it has generated tremendous impact worldwide. Since
its inception in the 1990's, Malaysian pharmacists have embarked on a bold and
dramatic leap forward to embrace its philosophy in all areas of pharmaceutical care
services. Much effort has been put into exploring ways in which to instil and initiate
pharmaceutical care activities in both the outpatient and inpatient settings.
Ward pharmacy activities encompass issues on all aspects of pharmacotherapy. During
ward rounds, input pertaining to appropriateness of therapy, counselling of patients on
medication therapy and the monitoring of unwanted side effects are the major
services provided. Often time, the input given is not documented. Thus, a mechanism
to document these activities is crucial and urgently required.
The pharmaceutical needs of a patient refer to his or her requirements for pharmaceutical
products or services. Pharmaceutical needs may be identified by any member of the
health care team or by the patient him/herself. Once a targeted patient group has been
assigned to the responsibility of a clinical pharmacist, a function of the delivery of the
service is to prioritise the individual patient in the group according to his/her potential
pharmaceutical care issues (PCI).
It is important to document the outcomes of the pharmaceutical care intervention for
the purpose of individual patient records as well as information for the management.
Information on issues such as drug availability, dosage form, procurement and
storage should be managed in liaison with colleagues in other units. Pharmacists
require both knowledge and clinical experience to be a useful member of the health
care team. Therefore the clinical pharmacist serves as a liaison person between
patients, doctors, nurses and fellow pharmacists.
Inpatient Pharmacy
Services
Inpatient
2.0
Drug
Distribution
2.0
Activities
DRUG DISTRIBUTION ACTIVITIES
Objectives
Drug Distribution
Activities
The pharmacy department should implement a distribution system that meets the
following objectives:
i. To dispense prescribed drugs to patients in wards in a timely and efficient
manner
ii.
To avoid occurence of medication error
iii. To minimise drug wastage

iv. To minimise opportunities for drug diversion
v.
To maintain information on drug utilization and rational drug use
vi. To identify unusual patterns of drug usage
Drug Distribution Method

Currently, three types of drug distribution systems are being practiced i.e. the
traditional system, unit-of-use system and unit dose system. The unit dose system
(UDS) should be encouraged due to its many advantages. The UDS involves dispensing
of drugs to individual patients on a daily basis and for 24 hour duration only. The unitof-use system (UoU) is similar to UDS in many ways except to the duration of supply.
Drug distribution system may be centralised or decentralised depending on location
and facility itself.
Other activities include:
i. Floor Stock / Emergency Trolleys Medication
ii.
After Office Hours Supply
iii. Supply For Psychotropic Medicines

iv. Supplies For Discharged Patients
v.
2.1
Ward / Unit Inspection
UNIT DOSE SYSTEM
All medications dispensed to patients in the wards should be kept in individually labelled
drawers or trays in the medication trolleys for patients. The amount of medication
dispensed should be according to the dosage regimen and placed in compartments
within the patient drawers. The medication trolley must be lockable and the keys kept
by a registered nurse in the specific ward and another by an authorised pharmacy
staff.
10
Drug
2.1.1
Distribution
Activities
2.0
Handling of Medication Trolley
2. The trolley has to be collected by ward staff before the next dose
administration time at 12.00 noon.
2.1.2
Medication Order
1. The medication order for ward patients must be completed in the
self-carbonised Medication Chart and signed by the prescriber
according to the categories set by the Ministry of Health Malaysia
Drug Formulary (FUKKM).
2. Each prescription must be written with the generic name, complete
with dose in mg, ml or IU; administration route such as SC, IM, IV,
PO, LA or others; administration frequency such as DAILY, BD, TDS,
QID etc; treatment duration such as 5/7, 1/52 or 2/52; starting date;
prescriber's signature; patient name and ward/bed number.
3. All prescriptions of medications for A, A/KK or A* categories must be
stamped and countersigned by the relevant specialist. Controlled
medicines must be attached with application forms according to the
practice in individual institutions.
4. All original prescriptions (white) from the Medication Chart should
be separated from the carbonised copy (yellow) (Appendix 1). The
carbonised copy should be retained in the ward.
5. A new medication order (prescription) must be made in the following
situations:
a) Newly-admitted patients
b) Patients transferred in from other wards
c) Patients who have just undergone an operation or special
procedures
d) Expired prescriptions but treatment needs to be continued
6. For patients who have just been admitted into the ward, the
prescription has to be sent with the patient's Cumulative Medication
Record (Appendix 2).
7. For patients currently in the ward, any addition of medications must
be made through a prescription. Any changes in dose, dosage form,
frequency or treatment duration warrants a new prescription attached
with an Advice Note (Appendix 3).
11
Drug Distribution
Activities
1. The medication trolley should be sent to the pharmacy by the nurse

on duty for the supply of new prescriptions and daily refilling of current
prescriptions after dose administration times, usually at 8.00am.
2.0
Drug
Distribution
Activities
8. The completed original prescription must be separated from the

self-carbonised copy, collected and sent to the pharmacy.
9. The nurse on duty is responsible for sending prescriptions for all
patients in the ward to the pharmacy. Under certain circumstances,
the nurse can direct the Penolong Perawatan Kesihatan (PPK) to
send the prescriptions to the pharmacy.
Drug Distribution
Activities
2.1.3
Receiving the Prescription

1. All prescriptions received must be checked by the Pharmacist/
Pharmacy Assistant to ensure that they are complete.
2. Screening of all prescriptions should be done by the pharmacist to
ensure the following:
a) Authenticity of prescription/prescriber
b) Adherence to FUKKM
c) Suitability of dosing regimen
d) Drug interactions
e) Polypharmacy
f)
Correct medication administration method and frequency
g) Others
3. For any other interventions, the Pharmacist/ Pharmacy Assistant
should either contact the medical officer concerned for clarification
or issue an Intervention Note (Appendix 4).
4. Any changes made to the prescription can only be made with the
prior consent of the prescriber concerned and recorded into the
'Notes' column of the CMR. If the countersignature for Category A
medications has not been obtained, the prescription should be
copied into the CMR and the medication supplied first while waiting
for the countersignature. The Intervention Note that states the
necessity for the specialist's signature should be sent to the ward
with the prescription. After it is signed, the prescription will be
returned to the pharmacy to be pasted on the CMR.
12
Drug
Distribution
Activities
2.0
5. All new prescriptions which have been screened should be pasted

on the patient's CMR and the expiry date of the prescription recorded
in the amount column.
For example:
Date Start
PATIENT'S NAME
C16-B2 Ooi Chooi Seng
12/10/09
DRUG
Prescriber's
signature &
stamp
Tab. Allopurinol 300mg
Dose
Route
1/1
PO
12/10/09
Amount
Date
Amount
NOTES
1 x 1
Drug Distribution
Activities
Date
MEDICATION RECORD
Frequency Duration
Daily
7/7
6. To discontinue a medication, the prescription at the CMR must be

stamped with "UBAT DIBERHENTIKAN". At the Medication Chart
(yellow copy) in the ward, the prescriber/pharmacist/nurse can record
the discontinuation of the medication in the yellow copy.
7. To withhold medication, it must be recorded as "WH" in the CMR at
the amount column. The same should be done for the Medication
Chart in the ward, which should be done by the doctor/ pharmacist/
nurse.
8. Changes in medication dose or administration frequency need to be
stamped with "RUJUK PRESKRIPSI BARU".
2.1.4
Filling of Prescriptions
1. All medications supplied to the ward must be in ready-to-use form in
a container meant for administration of one dose and not exceeding
the requirements for 24 hours.
2. Filling of prescription should be done by the Pharmacist/ Pharmacy
Assistant and counterchecked by another Pharmacist.
3. Filling has to be done for new prescriptions and current prescriptions
in the CMR.
13
2.0
Drug
Distribution
Activities
4. Amount of medication and frequency supplied for the day should be

written in the 'Amount' column of the CMR. [For example, Paracetamol
1g (2 tablets) QID will be recorded as 2 x 4 as below]:
Drug Distribution
Activities
DATE
12/10/09
AMOUNT DATE
AMOUNT DATE
AMOUNT NOTES
2X4
5. Pharmacy staff has to ensure the cleanliness of the medication trolley

and bins. All bins must be emptied before filling is done.
6. If there is a balance of medication in the patient's bin and no Advice
Note is given, explanation from the nurse on duty in the ward
concerned has to be obtained and recorded in the CMR.
7. One bin is allotted per patient. Each bin must be filled with the
medication prescribed, with the correct quantity based on the CMR
and in accordance with the administration times. Examples of
administration times are as follows:
Frequency
14
Time
4 hourly
6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am
QID
6 am, 12 noon, 6 pm, 10 pm
TDS
8 am, 2 pm, 8 pm
BD
8 am, 8 pm
ON
10 pm
OM
8 am
Before meal
6 am
Before meal BD
6 am (before breakfast), 6 pm (before dinner)
prn
Placed at the furthest end of the patient's bin.
Drug
Distribution
Activities
2.0
DATE
AMOUNT DATE
12/10/09 1 x 5ml
atau
1 x 30g
AMOUNT DATE
AMOUNT NOTES
TELAH DIBEKAL PADA
...............................................................
...............................................................
9. Filling of prescriptions involving psychotropic medications,

exchange basis drugs and floor stock items need not be done in a
unit dose manner and the prescription should be stamped with
EXCHANGE BASIS, USE PSYCHOTROPIC STOCK or USE FLOOR
STOCK.
10. Use the "SELESAI" stamp after the prescriptions have been
supplied in full.
11. For prescriptions where dosage forms of the medication are changed
from injection to oral, the CHANGE TO ORAL stamp should be used
and vice versa.
12. For PRN doses, the medications are placed at the back of the
individual bin. On the first day, the amount of doses supplied should
be recorded and for subsequent days, only the amount of doses
added needs to be recorded.
Example 1: Tab. Paracetamol 1g PRN.
DATE
AMOUNT
12/10/09
+8
13/10/09
+6
14/14/09
+2
15
Drug Distribution
Activities
8. For the dispensing of medications such as eye/ear drop solutions or

creams, the total volume or weight supplied must be recorded in the
"amount" column and stamped with "TELAH DIBEKAL PADA". For
example:
2.0
Drug
Distribution
Activities
Example 2: Tab. Chlorpheniramine 4mg TDS & PRN

DATE
AMOUNT
Drug Distribution
Activities
12/10/09
1x3+3
13/10/09
1 x 3 + 0 (not added)
14/14/09
1x3+2
The staffs filling the bins have to sign the Unit Dose Dispensing
Checklist (Appendix 5).
2.1.5
Checking the Supply (Countercheck)

1. All unit dose medication supply must be counterchecked by a different
pharmacy staff from the one who did the filling.
2. All medication filling and counterchecking process must be done
before the trolley collection time at 12.00 noon.
3. The nurse on duty should check the supply received and inform the
pharmacy if there are any discrepancies.
4. After checking the supply, the nurse on duty should receive the
medication trolley and acknowledge receipt in a form according to
the requirements of individual hospitals
5. All the filling errors need to be corrected and recorded for the
purpose of QAP Monitoring.
2.2
FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS
Wards are only permitted to keep a limited quantity of frequently-used medications. A

medication list which has been agreed upon by the pharmacy and the ward / unit should
be kept in the ward / unit and pharmacy. Level of floor stock / emergency trolley items
should be more than the minimum limit but should not exceed the maximum limit.
Floor stock / emergency trolley medication list should be reviewed periodically.
16
Drug
Distribution
Activities
2.0
The procedures for supplying Floor Stock / Emergency Trolley Medications are as
follow:
1. Receive medication order book from the ward / unit
2. Check balance of floor stock / emergency trolley medications
3. Record the quantity supplied in the order book
Drug Distribution
Activities
4. Supply medication according to the recorded quantity

5. File the original copy of the order book
2.3
AFTER OFFICE HOURS SUPPLY
Drugs prescribed after normal working hours will be supplied according to the amount
requested to the pharmacy staff on-call.
2.4
SUPPLY OF PSYCHOTROPIC MEDICINES
Wards may only keep psychotropic medicines in the amount permitted in a medication
list. A copy of the medication list as agreed upon by the pharmacy and the ward / unit
should be kept in the ward / unit and pharmacy. Record books must be updated each
time psychotropic medications are used based on valid prescription (order form).
The procedures for supply of psychotropic medicines are as follow:
1. Receive order form and psychotropic medications record book from the ward
/ unit.
2. Check order form and record of psychotropic medication use
3. Determine that the order is consistent with use and record the balance of
psychotropic medications
4. Record supply in the psychotropic medications register book
5. Record the quantity supplied and sign the psychotropic medications record
book and order form
2.5
SUPPLIES FOR DISCHARGED PATIENTS
Supplies for discharged patients should follow the same procedures as that of
dispensing at the counter. However for medication counselling (refer Chapter 3.5) and
bedside dispensing (refer Chapter 3.6), should ideally be carried out for the following
category of patients:
17
2.0
Drug
Distribution
Activities
1. Patients using devices (inhalers, insulin pen); to reinstate what has been taught
during ward stay.
2. Patients with several debilitating conditions who are on many different
medications.
3. Patients newly diagnosed with chronic illnesses
Drug Distribution
Activities
4. Patients on medications with narrow therapeutic index.

5. Patients who have poor understanding/knowledge/comprehension of
medication usage / regimen
2.6
HANDLING REFERRAL LETTER (SECOND COPY) AND SUPPLY OF

MEDICATIONS FOR PATIENTS BEING REFERRED TO HEALTH FACILITIES
The policy of Ministry of Health Malaysia stated that stable patients can be referred to
nearby health facilities (hospital or health clinic) by using referral letter, for the purpose
of continuing treatment. Proper handling of referral letter (second copy) and supply of
medications to referred patients are important since not all facilities keep certain
medicines. Pharmacy Department is responsible in ensuring that there is a policy/
procedure regarding the submission of referral letter (second copy) to Pharmacist at
the facility where the patient is referred to.
Objectives of proper handling of referral letter:
To ensure preparedness of medications at the referred facility
To ensure continuity of treatment
2.6.1
Referring patient by referring facility

1. The Medical Officer will fill in three copies of the referral letter
(Appendix 6).
The first copy is for the patient to bring to the referred facility
The second copy is to be given to the Pharmacist at the

referring facility
The third copy is to be kept in patient file at the referring facility
2. Pharmacist at the referring facility will review the patient's drug

regiment with the Pharmacist at the referred facility
18
If the referred facility does not keep the medicines, the referring
facility must supply enough medication until the next
appointment date at the referred facility
Ward
Activities
3.0
Both Pharmacists should also discuss the patient's next supply

of medications
3. Pharmacist at the referring facility must fax or post the second copy
of the referral letter to the Pharmacist at the referred facility, and if
necessary supply the medications to the referred facility before the
next appointment date
4. A copy of the second copy of the referral letter should be filed for
reference purposes
2.6.2
Receiving Second Copy at referred facility

1. Inform the referring facility upon receiving the second copy (and
supplied medications from the referring facility if necessary)
2. Review patient's drug regiment (and supplied medications from the
referring facility if necessary)
3. Register the patient's particulars into the Drug Supply Registry Book
(Appendix 7)
4. File the second copy of the referral letter
5. Dispense medications on the fixed appointment date
2.7
WARD / UNIT INSPECTION
Ward Inspection is done to ensure the following:

a. Ward stocks comply with the amount approved
b. Expiry dates of all drugs are clearly labelled
c. Drugs are properly labelled
d. Drugs are properly stored
e. Emergency drugs are available and in good order
f.
Medication trolleys are checked regularly
g. Refrigerated items are stored appropriately

h. Psychotropic drugs are used, stored and recorded according to the
requirements of existing laws
19
Drug Distribution
Activities
Pharmacy
2.0
Drug
Distribution
Activities
Criteria for Good Drug Distribution Service
Drug Distribution
Activities
Implementing the Unit Dose System
Appropriate storage of Ward Stock
Adequate Floor Stock level
Complete range of Emergency Drugs
Access to after office hours supply
Routine Ward / Unit Inspection
20
Ward
3.0
Pharmacy
Activities
3.0
WARD PHARMACY ACTIVITIES
Ward Pharmacy activities should be in line with the concept of Pharmaceutical Care
i.e. patient-centred, outcomes-oriented pharmacy practice. It requires the pharmacist
to work in concert with other healthcare providers to promote health, to prevent
disease, and to assess, monitor, initiate and modify medication towards ensuring that
drug therapy regimens are safe and effective.
ii.
Ward Pharmacy
Activities
The goal of ward pharmacy activities is to optimise the patient's pharmacotherapy and
achieve positive clinical outcomes within realistic economic expenditures. Four types
of forms are designed to document ward pharmacy activities:i. Medication History Assessment Form (CP1)
Pharmacotherapy Review (CP2)
iii. Clinical Pharmacy Report Form (CP3) and

iv. Discharge Referral Note (CP4)
Ward pharmacy activities include the following:
i. Medication History Taking
ii.
Case Clerking
iii. Pharmacotherapy Rounds (including routine rounds, pharmacists' rounds and

grand ward rounds)
iv. Medication Reviewing
v.
Medication Reconciliation
vi. Medication Counselling

vii. Discharge Planning
Tips to Achieve Pharmaceutical Care Goals
Establish and maintain professional relationships with patients and other healthcare team
members.
Collect, organise, record and maintain patient-specific medical information.
Evaluate patient-specific medical information and develop good rapport with patients.
Ensure that the patient has all supplies, information and knowledge necessary to carry
out the drug therapy plan.
Review, monitor and modify therapeutic plan when necessary and in concert with the
patient and healthcare team.
21
3.0
Ward
3.1
Pharmacy
Activities
MEDICATION HISTORY TAKING
Medication history taking by pharmacists is essential for retrieving missing information

with regard to prescription medications which the patient is currently on, information
on past drug history as well as self-medication. This additional information can be an
invaluable aid for pharmacists and other healthcare providers in assessing and
determining the best treatment options towards optimising patient care.
Objectives of medication history taking:
Ward Pharmacy
Activities
To gauge the patient's understanding towards their medications
To ensure continuity of medication treatment
To elucidate information on non-compliance towards drug treatment
To ascertain if patients are taking other forms of medications such as

supplements, over-the-counter (OTC) medicines and herbal preparations.
The Medication History Assessment Form (CP1) should be used as a guide for effective
medicine history taking. The form should be kept with the patient's case notes to serve
as a reference for other healthcare providers.
Important Points for Effective Medication History Taking
List
all current medications,
including self-prescribed medication supplements and herbal
3.4
MEDICATION
REVIEWING
preparations with dosages and dates of commencement.
Medication orders should be reviewed for incomplete prescriptions, inappropriate drug

Write
down
the medication
history of previous
thatadministration
may be relevanterrors,
to the present
use,
unclear
instructions,
authenticity
of the treatment
prescriber,
appropriatetreatment
drug storage
and
other
issues
related
to
patient's
drug
management
in
the
ward
and any reason for changes or alterations in the regimen.
to determine the pharmacotherapeutic appropriateness of each order for the individual
patient.
Note history of allergy or adverse drug reactions to any particular drug / food.
3.5
MEDICATION
RECONCILIATION
Assess
compliance.
Record any problem related to medications (e.g.: storage, supply, containers, labelling etc).
3.2 CASE CLERKING

Case clerking and medication review are often done concurrently. Most PCIs and
potential pharmaceutical interventions are identified during these two activities.
Pharmacists should play an active role in recognising these issues and documenting
them into the case notes. If the PCI is significant to the patient's current medication
plan, the issue should be highlighted to other healthcare providers during ward rounds
or wherever necessary. Efficient case clerking and reviewing require skills to keep
pharmacists focused on the active pharmaceutical care plans and interventions.
22
Ward
Pharmacy
Activities
3.0
Case clerking should be done for all new admissions as far as possible. The subsequent
revision of the case is known as case reviewing. Recurrent admissions should be
treated as new admissions, thus requiring new case clerking to be performed. All
findings, suggestions and interventions performed pertaining to PCIs during case
clerking / reviewing should be documented in the Pharmacotherapy Review Form (CP2)
for continuous follow-up to achieve targeted pharmaceutical outcomes.
Once the form is completed, the case should be reviewed and updated on a daily
basis until the patient is discharged. Patient's progress should be monitored by
analysing objective and subjective parameters, updating current pharmaceutical care
issues and intervening accordingly when necessary.
Able to extract relevant information from medication chart, case notes, laboratory data,
Medication History Assessment Form and relevant details from patient interview
Identify PCI
Analyse relevant data according to specific pharmaceutical care issues (PCI)
Differentiate PCIs from physician's management plan
Possess relevant clinical knowledge
Analyse relevant laboratory results
Summarise clinical findings
3.3
PHARMACOTHERAPY ROUNDS
Active participation in ward rounds requires good rapport with other healthcare teams,
up to date knowledge on drugs and information on drug availability and dosage forms.
The following 4P easy steps should be adapted to get started: Prepare, Participate,
Perform and Prove.
23
Ward Pharmacy
Activities
Skills for Efficient Case Clerking
3.0
Ward
Pharmacy
Activities
STEP 1: PREPARE
Familiarise oneself with drugs commonly used in the ward. Create your own pocket-size
drug reference
e.g.: drug list, normal dose, dosage adjustment in renal/hepatic failure
Review schedule for ward rounds
Bring along necessary forms, documents, references and other helpful tool, e.g.: calculator,
PDA, stamp
Review medication chart and patient's progress notes to identify cases that need to be
monitored
Ward Pharmacy
Activities
STEP 2: PARTICIPATE
Participate effectively during discussion by presenting relevant PCI.
Practise diplomacy in dealing with patients and other healthcare providers.
Be discreet about what is discussed in the presence of the patient and caregivers.
Outline therapeutic plan, when required.
Intervene when necessary and monitor outcome of intervention.
STEP 3: PERFORM
Review patient's progress based on targeted outcome.
Respond to questions and enquiries promptly.
Follow up on pharmaceutical care interventions and review accordingly.
Update patient's progress in the Pharmacotherapy Review Form.
STEP 4: PROVE
Record all interventions and activities in the appropriate form.
Keep all documentations in patient's folder for future reference.
24
Ward
3.4
Pharmacy
Activities
3.0
MEDICATION REVIEWING
Medication orders should be reviewed for incomplete prescriptions, inappropriate drug

use, unclear instructions, authenticity of the prescriber, administration errors,
appropriate drug storage and other issues related to patients drug management in the
ward to determine the pharmacotherapeutic appropriateness of each order for the
individual patient.
Ensure that medication order is comprehensible and in accordance with local requirements
Ensure that any drug / food allergens are documented / displayed prominently in the
patient's case notes / records
Ensure appropriateness of medication order and administration times.
Check whether dosages ordered have been administered.
Detect any problem related to intravenous administration, including potential incompatibilities,

drug stability, volume of intravenous fluid for medication administration and rate of
administration
Ensure that all ceased orders are cancelled in patient's drug profile drug order form
Sign and date the chart after checking the above
3.5
MEDICATION RECONCILIATION
Medication reconciliation is a systematic process where all medications are correctly

and consciously continued, discontinued or modified in a timely manner at each point
in which the patient moves through the various levels of the health care continuum. It
is a formal process for creating the most complete and accurate list possible of a
patient's current medications and comparing the list to those in the patient record or
medication order. Pharmacists should perform medication reconciliation at all points
of care.
The objectives of the medication reconciliation are:
i. To ensure that the most accurate patient medication list is available to all care
providers, especially at the point of transition of care (admission, transfer and
discharge). Transitions in care include changes in setting, service,
practitioner or level of care.
25
Ward Pharmacy
Activities
Medication Review Checklist
3.0
Ward
ii.
Pharmacy
Activities
To ensure timely and accurate documentation of a comprehensive list of

patient's medications.
iii. To ensure communication of this information across the continuum of care.

iv. To reduce medication-related errors at each transfer of care.
v.
To improve patient safety and optimise health outcomes.
3.6 MEDICATION COUNSELLING
Ward Pharmacy
Activities
Non-adherence to therapy can be due to various reasons such as patient's lack of

understanding, inappropriate / inadequate instructions, complicated regimens or
failure to fill a prescription. Ward pharmacists should conduct a patient-oriented
interview, review medications, make appropriate recommendations to prescribers and
/ or patients themselves, and monitor patient outcome. Counselling is a professional
relationship and activity which a pharmacist undertakes to enhance patients'
knowledge on their pharmacotherapy and improve compliance to medications by giving
professional advice, proper instructions and provision of aids where necessary.
There are various ways to conduct medication counselling - individual (bedside or
discharge) and group counselling. Bedside counselling is the counselling given to the
patients in the ward. Discharge counselling is the counselling given to the patient to
ensure that the patient/care-giver has a proper understanding of how to self-medicate
upon discharge. Group counselling is counselling given to a group of patients with
similar disease states. e.g. Warfarin group counselling, Diabetic group counselling,
Cardiac Rehabilitation Program, etc.
Pharmacists' thorough understanding of the patient's condition and disease are
essential in order to get the patients involved in their drug therapy plan during
medication counselling. The pharmacist should ensure that the patient is counselled
on all prescribed medicines and stress on the need to adhere to the prescribed regimen.
This is especially important for patients with a history of poor compliance.
In designing an outcome-oriented drug therapy plan, the pharmacist should carefully
consider the psychosocial aspects of the medical conditions as well as the potential
relation between the cost and/or complexity of therapy and patient adherence.
The following information should be provided to the patient:
26
generic name and brand name of drugs prescribed
intended purpose and expectation for a medication used
dosage regimen
route of administration of a medication
Ward
Pharmacy
Activities
3.0
common side effects
special directions or precautions for the preparation and administration of a

medication
information on relevant drug-drug, drug-food, drug-alcohol and drug test /

procedure interactions
storage conditions
action to be taken in the event of a missed dose
Use the following easy steps for effective medication counselling.
Ward Pharmacy
Activities
STEP 1: PLAN
Prioritise potential patient for counselling based on:
Complexity of therapeutic plan
Compliance status
Patient with special device needs
Patient dependant on caregiver.
Decide the type of counselling needed for each individual patient. For those with similar
medical problems / drug therapy, group counselling can be recommended.
STEP 2: PREPARE
Study the patient medication profile, relevant medical history, social history and other
related information prior to counselling.
Identify relevant issues to be emphasised during counselling.
Develop an individualised outcome-oriented drug therapy plan.
Select counselling tools (eg. flip chart, pamphlet, sample device etc).
Schedule counselling session.
STEP 3: CONDUCT
Educate on drug knowledge and disease.
Discuss and educate patient's therapeutic plan.
Enhance compliance to medication and treatment by having follow up sessions.
27
3.0
Ward
Pharmacy
Activities
Documentation and follow-up:

Follow-up counselling sessions may be necessary during ward stay and upon
discharge. Information provided during the counselling sessions should be documented
in the case notes and Pharmacotherapy Review form (CP2) by the ward pharmacist.
Counselling statistics should be recorded in the Clinical Pharmacy Report form (CP3).
Patients who require continuity of care in other healthcare setting should be referred
using the Discharge Referral Note (CP4).
3.7 DISCHARGE PLANNING

Ward Pharmacy
Activities
Ensuring continuity of care when patients are transferred from one hospital to another
institution requires effective cooperation between fellow pharmacists and doctors to
whom responsibilities are transferred.
The objectives of discharge planning are:
i. To reduce medication discrepancies after the patient is discharged from the
ward
ii.
To save cost through the use of patients' own drugs
iii. To ensure better drug knowledge and to enhance compliance to medicines

prescribed
iv. To make provision for continuity of care.
3.7.1
Transcribing Discharge Medication into the Prescription

This activity should be done based on approval of the hospital management
and the doctors in charge of the ward. When a patient is ready to be
discharged, the doctor will write all the discharged medicines in the bed head
ticket (BHT). The ward pharmacist may take on the responsibility for
transcribing the medications which the patient is on into the prescription slip.
All discharged prescriptions should be initialled by the pharmacists, counter
checked by another pharmacist and signed by the attending physician. The
transcribing of the discharge prescription will allow the doctor to save time
during the process of discharging patients and will enable the patient to leave
earlier. However, the doctor must be fully aware that the final responsibility for
the prescription still lies with the doctor.
3.7.2
Preparation of Discharge Medications

Discharge Summary (Appendix 8) comprise of list of patients being discharged
on a particular day. It should be sent together with the discharged
prescriptions to the inpatient / satellite pharmacist, who is responsible for
28
Ward
Pharmacy
Activities
3.0
screening and counterchecking for any errors. If any error is detected, the
inpatient / satellite pharmacist should call the ward pharmacist to do the
intervention. Discharge medication will be prepared by the inpatient / satellite
pharmacist and sent to the ward for bedside dispensing.
Use of Patient's Own Drugs for Discharge
By performing medication reconciliation, the ward pharmacist would have
known if there is any balance medicines from the previous supply. If there is
balance of medication and is found to be in a good condition, it should be
reused as far as possible. Any excess or remaining previous medications that
are discontinued in the ward should be returned to the pharmacy. The aim of
this scheme is to optimize the use of current medications kept by patients
and reduce wastage.
3.7.4
Bedside Dispensing and Discharge Counselling

The objectives of this activity are:
i. To speed up the patients discharge
ii.
To enhance patients satisfaction
iii. To reduce number of patients at the outpatient department

iv. To promote better medicine knowledge and compliance
Bedside dispensing and discharge counselling will be done by the ward
pharmacist. The ward pharmacist has to counsel the patient or family
members on the medications prescribed, supply counselling aids (where
necessary) and address any PCIs. Wards without a ward pharmacist can
have the medication dispensed by the inpatient pharmacist, or any
pharmacists on duty according to schedule.
29
Ward Pharmacy
Activities
3.7.3
4.0
Other
4.0
Activities
OTHER ACTIVITIES
Other activities in the Inpatient Pharmacy include the following:

4.1
Clinical Pharmacokinetic Service
4.2
Drug Information Service
4.3
Adverse Drug Reaction Monitoring and Reporting
4.4
Medication Error Reporting
4.5
Product Complaint Reporting
4.6
Processing Requests for Non-Formulary Medications
4.1
CLINICAL PHARMACOKINETIC SERVICE
Other Activities
Clinical Pharmacokinetic Service ensures safe and efficacious dosage regimens

through the application of pharmacokinetic / pharmacodynamic principles and the
determination of drug serum concentrations. At the same time this service provides
invaluable information regarding the toxicity level of the following drugs:
30
Aminoglycosides (amikacin, gentamicin)
Benzodiazepine
Carbamazepine
Digoxin
Lithium
Phenobarbital
Phenytoin
Theophylline
Valproic acid
Vancomycin
Paracetamol
Salicylates
Tacrolimus
Cyclosporine
Other
4.2
Activities
4.0
DRUG INFORMATION SERVICE
Pharmacists should serve as effective providers of drug information. All drug

information requests from healthcare professionals / consumer / patients should be
responded to immediately. By proper dissemination of drug information, the chances
of medication errors can be prevented. This service can improve awareness and
knowledge on health among the public in the quality use of medicine and pharmaceutical
products. Moreover, it can promote patient care through rational use of drugs.
Drug Availability
Drug Identification
Dosage/Administration
Indication
Interaction
Contraindication / Precaution
Adverse reactions / Side effects
All entertained enquiries should be properly documented to serve as future references.
4.3
ADVERSE DRUG REACTION MONITORING AND REPORTING
An Adverse Drug Reaction (ADR) is any unexpected, unintended, undesired, or

excessive response to a drug that:
requires discontinuing the drug (therapeutic or diagnostic)
requires changing the drug therapy
requires modifying the dose (except for minor dosage adjustments)
necessitates supportive treatment
significantly complicates diagnosis
negatively affects prognosis or
results in temporary or permanent harm, disability or death
It is the pharmacist's responsibility to monitor and report any suspected adverse drug
reactions (ADR).
31
Other Activities
Enquiries may include the following categories:
4.0
Other
Activities
Process of Reporting by the Ward Pharmacist:

The occurrence of untoward reactions found to be caused or suspected to be caused
by a drug should be investigated and verified. The event should be highlighted to the
prescriber or pharmacist. The adverse drug reaction should be verified and an Adverse
Drug Reaction report should be completed by the doctor or pharmacist. The Drug
Information Service (DIS) pharmacist should compile and submit the report to Malaysian
Adverse Drug Reactions Advisory Committee (MADRAC). Reports may be submitted
on-line or by posting the ADR form to MADRAC. Confidentiality of the reaction and
patient information must be maintained at all times. The Malaysian Guidelines for
Reporting and Monitoring of ADR can be obtained from the National Pharmaceutical
Control Bureau NPCB) website.
Other Activities
A description of the adverse reactions and the suspected drug should be recorded in
the patient's bed head ticket / case note. The patient should be informed of the reaction
and adequate advice given taking care to avoid legal implications. An allergy card should
be given to the patient for documentation and as a form of alert for future drug use. The
number of Adverse Drug Reaction events should be recorded in the Clinical Pharmacy
Report Form (CP3). The data should be analysed to study trends in the occurrence of
ADRs to identify drugs which are commonly implicated, changes in the frequency of
occurrence and at risk groups. This information should be presented to the Drugs &
Therapeutics Committee if deemed necessary.
4.4
MEDICATION ERROR REPORTING
A medication error is defined as any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of
the health care professional, patient, or consumer. Such events may be related to
professional practice, health care products, procedures and systems, including
prescribing, order communication, product labelling, packaging and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring and use.
When reporting errors, please consider the following:
1. Describe the error or preventable adverse drug reaction. What went wrong?
2. Was this an actual medication error (reached the patient) or are you expressing
concern about a potential error or writing about an error that was discovered
before it reached the patient?
3. Patient outcome
4. Type of practice site (hospital, private office, retail pharmacy, drug company,
long-term care facility, etc)
5. The generic name (INN or official name) of all products involved
6. The brand name of all products involved
32
Other
Activities
4.0
7. The dosage form, concentration or strength

8. How was the error discovered/intercepted?
9. Please state your recommendations for error prevention.
Pharmacist can refer to Guideline on Medication Error Reporting and submit the ME
report form (Appendix 12) to Pharmaceutical Services Division.
4.5
PRODUCT COMPLAINT REPORTING
4.6
PROCESSING REQUESTS FOR NON FORMULARY MEDICATIONS
Each hospital / institution should have its own drug formulary adapted from the MOH
drug formulary based on local needs and functions. The hospital formulary may not
include all drugs in the MOH formulary. Newly-approved MOH drugs should follow the
local hospital policy for inclusion into the hospital formulary. Formulary drugs should
be the preferred choice of use at all times.
Drugs not listed in the MOH formulary are called Non-MOH Formulary Medications and
should not be prescribed before getting prior approval from the Director General of
Health. However, when non-hospital formulary drugs are strongly indicated (in
circumstances such as life-threatening situations or no other alternatives are available),
it should go through the proper procedure for approval before it can be obtained.
Ward Pharmacists in collaboration with the DIS pharmacist should ensure that nonMOH formulary drug requests for inpatients are rational and based on current evidence.
The prescriber should submit the request by using the 'KPK 01' Form with justification
by the respective Head of Department. All requests should be submitted to the
Pharmaceutical Services Division, MOH for approval by the Director General of Health.
The pharmacy department should monitor the non-MOH formulary drug usage once it
is available in the hospital.
33
Other Activities
Complaints on the quality, lack of efficacy, packaging, labelling, etc. of pharmaceutical

products by other healthcare professionals should be looked into by the
ward pharmacist. The reporter should fill in the Product Complaint Form (BPFK 418)
and quarantine the related product. The DIS pharmacist should submit the form together
with the sample to the Centre for Product Post Registration, NPCB for further action.
5.0
Documentation
5.0
DOCUMENTATION
Data collection through systematic documentation can be used for future planning
and expansion of pharmacy services in the country. Drug information enquiries during
the ward rounds should also be recorded in the Clinical Pharmacy Report Form. Areas
of national importance such as cost savings and medication error reduction can be
utilised to enhance a particular service. Please refer appendices for types of forms
used in Inpatient Pharmacy Practice.
5.1
UNIT DOSE SYSTEM (UDS) FORMS
Please refer to Chapter 2.1 for the use of the UDS forms.
5.2
WARD PHARMACY FORMS

5.2.1
Medication History Assessment Form (CP1)
Introduction
Documentations
As patients who are admitted to the ward may already be on some form of
medication, it is important to obtain this information prior to initiating treatment
except in an emergency setting.
A patient's treatment may be improved by an accurate drug history which
highlights drug related causes for previous treatment failure, previous and
potential adverse reactions, interactions, allergic, compliance, etc. The
medication history should be filed together with patients medical progress notes
(original copy) and for pharmacy record (carbonized copy) to facilitate easy
reference during the patient's stay in hospital.
Objectives
34
To obtain a complete patient medication history within 24 hours of admission

in order to improve the provision of pharmaceutical care.
To design a pharmaceutical care plan with the doctor and patient.
Documentation
5.0
This form is divided into 5 sections:

A. Patient Biodata
B. Reason For Admission
C. Allergy and Adverse Drug Reaction
D. Drug History
E. Pharmacist Notes
How to Complete Form CP1:
Patient Biodata
B.
Reason for Admission
C.
Obtain information from patient or care giver
Allergy and Adverse Drug Reaction History
D.
Obtain the patient's biodata (name, MRN, identity card number,

address and contact number) and other required information (past
medical history, admission date/time, ward of admission, the
medical doctor in charge, diagnosis, last discharge/review date, last
encounter date at any hospital or clinic) from the Bed Head Ticket
(BHT) or any of your hospital information retrieving system.
Obtain allergy and adverse drug reaction history by interviewing the

patient or care giver and by reviewing past medical notes if available
Record all confirmed, suspected and possible allergies and adverse
drug reactions
Record No Known Drug Allergy or NKDA if the patient has no history
or unknown drug allergy and adverse drug reaction
Drug History
Obtain information on prescribed and non-prescribed medications

including use of traditional/complementary medicines from the
patients or their caregiver
Request the patient or care giver to bring prescribed and
non-prescribed home medications, which the patient is currently on
Check the physical condition, label and dosage of the drugs and record
accordingly in the form
Obtain the actual dose regimen taken by patient and compare with
the dosing regimen on the label
35
Documentations
A.
5.0
Documentation
E.
Pharmacists Notes
5.2.2
Record patient's compliance status and their medications related

problem
Plan pharmaceutical care interventions to improve patients' drug
therapy, compliance and understanding to treatment
Pharmacotherapy Review (CP2)
Introduction
Continuous pharmaceutical monitoring is essential to achieve optimum outcome
from the care plan which has been designed for the patient.
Objectives
To obtain a complete patient medication history within 24 hours of

admission in order to improve the provision of pharmaceutical care.
To plan, detect and monitor pharmaceutical care issues
To following on patient's response to the prescribed drug therapy
To update pharmacy-patient database for the purpose of discussion,
evaluation, as a learning tool as well as for the conduct of research,
and studies
Documentations
Form Contents
The form is divided into 5 main sections:
Section 1 - Appendix 10a
Section 2 - Appendix 10b & 10c
Section 3 - Appendix 10d &10e
Section 4 - Appendix 10f & 10g
Section 5 - Appendix 10h
: Patient's Profile
: Patient's Medication
: Lab Investigations
: Pharmaceutical Care Issues / Plan
/ Outcome
: Discharge Medication
How to Complete Form CP2
36
Section 1
Obtain information from patient's BHT and Medication History
Assessment Form (Form CP1). If required interview patients for
further information.
Documentation
5.2.3
5.0
Section 2
Obtain information of medications which the patient has been
prescribed / is on from the Medication Chart. Record complete drug
regimen, date start and date stopped.
Section 3
Obtain information from BHT or Hospital Laboratory Data Retrieving
System. Record significant lab values related to the pharmaceutical
care plan and treatment goal.
Section 4 (Monitor patients progress)

Record all ongoing pharmaceutical care issues, therapeutic plan,
therapeutic assessment and follow-up required.
Section 5
Record all discharged medication, and write the next appointment
date.
Clinical Pharmacy Report Form (CP3)
Introduction
Objectives
To document pharmaceutical interventions for the purpose of Quality

Assurance Programme (QAP) monitoring.
To record daily activities and workload of ward pharmacists.
To ensure continuity of pharmaceutical care in situations where
passing over of information is required when the primary pharmacist
is away temporarily or off duty.
Forms Contents
This form is divided into 4 sections.
37
Documentations
Data collection is critical towards justifying for the future expansion of clinical
pharmacy services and professional development and recognition in this country.
5.0
Documentation

Each form is to be filled on a daily or weekly basis depending on the practice in
the ward in individual hospitals.
A. Ward Pharmacy Activity
Routine round is the daily ward round conducted by the ward

pharmacists together with the medical officers. The specialist /
consultant in charge may or may not attend.
Grand round is the scheduled departmental round in which the ward
pharmacists participate with the consultants, specialists, medical
officers and nursing staffs.
Pharmacists round is the pharmacotherapy ward round involving the
ward pharmacist with other fellow pharmacists.
No. of cases clerked are the number of patients being clerked during
new admissions.
No. of cases reviewed are the clerked cases that are reviewed on
the following days.
No. of patients in the ward are the total numbers of patients in the
ward on a particular day
B. Interventions / Requests Encountered

Documentations
This refers to pharmaceutical interventions where there is an action

that produces an effect or alteration in optimizing patient's
pharmacotherapy. Pharmaceutical interventions are divided into four
types namely Incomplete Prescription, Incorrect/ Inappropriate/
Inadequate Regimen, Inappropriate Prescription and Miscellaneous.
Examples of TDM interventions are; identification of patients who
require TDM, advice on appropriate sampling time, suggestions on
dosage adjustment based on the TDM results.
Examples of TPN interventions are; recommendation for TPN therapy,
suggestion for appropriate TPN regimen, changes made to TPN
therapy based on patient's response and outcome.
C. Description of Requests / Intervention Encountered
38
This section summarises number of interventions done and number

of request / information provided as in section B.
Documentation
5.0
D. Follow Up Required
5.2.4
This section is to transcribe any pharmaceutical care issues from

Form CP2 during clerking and medication reviewing for further
follow-up and clarification if required. This section is an important
means of communication to ensure the continuity of pharmaceutical
care when the primary pharmacist is temporarily off duty or on leave.
Discharged Referral Note (CP4)
Introduction
The Discharge Referral Note (Appendix 12) should serve as a pharmacy
discharge summary to be given to the primary care pharmacist or doctor. The
patient should also be given the Discharge Referral Note for provision of further
counselling and be informed that he / she is required to see the pharmacist in the
follow-up facility.
The ward pharmacist identifies patients who require further monitoring for
referral. The patient's diagnosis, medication list and discharge instructions in
the patient's case notes should be reviewed. Pharmacists should fill in the
Discharge Referral Note (CP4 - Appendix 10) to ensure further reviewing or
counselling by the pharmacist in other healthcare setting takes place. All PCIs
and action taken should be documented in the patient's case notes.
39
Documentations
6.0
References
6.0
REFERENCES
Dooley, M. J., Allen, K. M., Doecke, C. J., et al. 2003. A Prospective
Multicentre Study of Pharmacist Initiated Changes to Drug Therapy and
Patient Management in Acute Care Government Funded Hospitals. Br.
Journal Clinical Pharmacology, 2003 : 67;4 : 513-21.
Kok Thong Wong, Siang Kwang Lim, Ruhaiyem Yahaya et al. 2001.
Guidelines Towards Excellence in Clinical Pharmacy Practice. Petaling
Jaya: Pharmaceutical Services Division, Ministry of Health.
Mohd Syafiq Abdullah, Kok Thong Wong, Rosnani Hashim et al. 1996.
Clinical Pharmacy Practice in the Malaysian Health Service: Concept
and Manual. Petaling Jaya: Pharmaceutical Services Division, Ministry
of Health.
Pharmaceutical Services Division, Ministry of Health. 2009. Requirement
for the Development of Pharmacy Facilities. Petaling Jaya:
Pharmaceutical Services Division, Ministry of Health.
References
40
Appendices
7.0
7.0
APPENDICES
The forms used in Inpatient Pharmacy Practice are as follows:

MR - Medication Chart
Appendix 1
CMR - Cumulative Medication Record
Appendix 2
Advice Note
Appendix 3
Intervention Note
Appendix 4
Unit Dose Dispensing Checklist
Appendix 5
Referral Letter
Appendix 6
Drug Supply Registry Book
Appendix 7
Discharge Summary
Appendix 8
CP1 -Medication History Assessment Form
Appendix 9
CP2 -Pharmacotherapy Review
Appendix 10
CP3 -Clinical Pharmacy Record Form
Appendix 11
CP4 -Discharge Referral Note
Appendix 12
Report on Suspected Adverse Drug Reaction
Appendix 13
Medication Error (ME) Report Form
Appendix 14
Product Complaint Form
Appendix 15
Appendices
41
Appendices
Appendices
42
Appendix 1
MEDICATION CHART
NAME : ...................................................
AGE
I/C : ........................................................
WEIGHT
: ..
R/N
DIAGNOSIS : ..
: ...................................................
WARD / BED : ........................
MEDICATION RECORD
Date
Time
Name/Ward/Bed
DRUG
Date
Prescriber's
signature & stamp
Route
Freq
Name/ Ward/ Bed

DRUG
Dose
Date
Prescriber's
signature & stamp
Route
Freq
Name/ Ward/ Bed

DRUG
Dose
Prescriber's
signature & stamp
Route
DRUG
Freq
Duration
Date
Prescriber's
signature & stamp
Route
Freq
Name/ Ward/ Bed

DRUG
Dose
Duration
Date
Name/ Ward/ Bed
Dose
Duration
Duration
Date
Appendices
Dose
ALLERGY
Prescriber's
signature & stamp
Route
Freq
Duration
Note : original prescription (white)

carbonised copy (yellow)
43
Appendix 2
CUMULATIVE MEDICATION RECORD

PATIENT PARTICULAR
NAME : ...................................................
AGE
I/C : ........................................................
WEIGHT
: ..
R/N
DIAGNOSIS : ..
: ...................................................
WARD / BED : .......................
MEDICATION RECORD
ALLERGY
Date Amount Date Amount Date Amount
Note
Appendices
44
Appendix 3
Inpatient Pharmacy
Hospital ________________
ADVICE NOTE
Date :___________ Time :_________
Patient
: _________________________________________________________________________
I.C. No.
: _____________________________
R/N
: ______________________
Ward
: _____________
Bed No.
: _______________
Age
: ___________ years
Weight
: ________ kg
Diagnosis: _____________________________________________________
Dear Pharmacy staff,
With regards to this patient, we wish to advice the following:
New admission
Discharged / Deceased
Transferred from Ward _______
Bed no. ________
to Ward _______
Bed no. ________
Medication stopped / changed ____________________________________________

______________________________________________________________________
Other ___________________________________________________________________
______________________________________________________________________
For pharmacy use only:
Appendices
__________________________
Sign & Stamp
45
Appendix 4
Inpatient Pharmacy
Hospital ________________
INTERVENTION NOTE
__________________________________________________________________________________
Dear Doctor / Staff Nurse,
Kindly ammend this patient's prescription as per the following:
Specialist's signature required (for List A drugs)
LP form incomplete / required
Prescriber's signature missing
No CMR
Clarify drug name
Clarify patient's name / bed number
Other: ________________________________________
________________
Date
____________________________
Sign & Stamp
Appendices
46
Appendix 5
Unit Dose Dispensing Checklist
Inpatient Pharmacy Service, Hospital ................................
WARD:
YEAR:
Month
JANUARY
SATELLITE:
FEBRUARY
MARCH
Received by:
Charted:
No. Errors:
Checked:
Dispensed:
Received by:
Charted:
No. Errors:
Checked:
Dispensed:
Received by:
Charted:
No. Errors:
Checked:
Dispensed:
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Appendices
25
26
27
28
29
30
47
Appendix 6
KEMENTERIAN KESIHATAN MALAYSIA
SURAT RUJUKAN
HOSPITAL ______________________
Tarikh Temujanji:
Rujukan mestilah kepada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital

Kepada
Tarikh
:
:
Nama Pesakit
No.K/P
Jabatan / Unit
Masa
Umur
Jantina :
No. Rujukan Tuan
No. Rujukan Kami
History & Physical Findings
Results of Investigations :
Diagnosis
Treatment
Purpose of Referral
Daripada Pegawai Perubatan / Pendaftar / Pakar / Pengarah Hospital

Nama
Hospital / Jabatan / Unit
Tandatangan
Tel
Appendices
Nota : Sila isi borang dalam 3 salinan

Salinan Pertama
: Diberi kepada pesakit (untuk diberi kepada doktor di institusi yang dirujuk)
Salinan Kedua
: Diberi kepada Pegawai Farmasi hospital merujuk (untuk difaks/ pos

kepada Pegawai Farmasi hospital / klinik dirujuk)
Salinan Ketiga
48
: Disimpan dalam fail pesakit
Appendix 7
BUKU DAFTAR PEMBEKALAN UBAT
(Drug Supply Registry Book)
BAGI PESAKIT YANG DIRUJUK BAGI MENERUSKAN RAWATAN KE

FASILITI KESIHATAN LAIN
Hospital / Klinik Kesihatan / Negeri : ____________________________
Tahun
No Rujukan
Borang
Sumber
Rujukan
(Hospital
asal yang
merujuk)
Bekalan Ubat Kategori A serta ubatubat yang tiada dalam formulari

(Tempoh Sebulan)
Nama dan Kuantiti
kekuatan dibekal
ubat
Kos (RM)
Tempoh
pesakit
dirujuk
Jumlah
Kos (RM)
Appendices
Tarikh
: _______________
Jumlah
49
Appendix 8
Inpatient Pharmacy
Hospital ________________
DISCHARGE SUMMARY
Dear Pharmacy staff,
WARD: __________
We wish to advice that the following patients have been discharged:

Bed No.
Reg. No.
For pharmacy use only:
Patients Name
___________________
(Staff Nurses Name)
Date : _____________
Appendices
50
Appendices
Appendix 9a
51
Appendix 9b
Appendices
52
Appendix 10a
CP2
PHARMACOTHERAPY REVIEW
PHARMACOTHERAPY
REVIEW
Pharmacy Department, Hospital ______________

Ref. no:
ALLERGY
Name :
Race : M / C / I / Others
MRN :
Ht/Wt :
Age :
Gender : M / F
DOA :
Ward/Bed :
Chief Complaint:
History of Present Illness:
Past Medical History:
Social/Family History:
Review of system:
BP:
mmHg
PR:
p/min
RR:
T:
b/min
O
Smoking
Alcohol
Drug
Abuse
Pregnant
Past Medication History:
Compliance Evaluation:
Appendices
Diagnosis/Surgical Procedure:
Sign & Stamp:
Pind 1//10
53
Appendix 10b
WARD MEDICATION
DATE START
DATE STOP
Appendices
ELECTROLYTE THERAPY
CARDIOVASCULAR
ANTIBIOTIC
DRUG / REGIMEN
54
Appendix 10c
WARD MEDICATION
DATE START
DATE STOP
OTHERS
DIABETES
DRUG / REGIMEN
Dopa
Dobu
Norad
Mida
Morp
Mida/Morp
Appendices
INFUSION CHART
DATE
I/O
CHART
Insulin
INPUT
OUTPUT
BALANCE
55
FBC
BUSE / Renal Profile
Urea
Na
K
Cl
Ca
Mg
PO4SCr
ClCr
1.7-8.3 mmol/L
135-145 mmol/L
3.5-5.0 mmol/L
96-106 mmol/L
2.1-2.6 mmol/L
0.7-1.3 mmol/L
0.8-1.45 mmol/L
64-122 umol/L
105-150 mL/min
Liver
profile
Albumin
T.Bilirubin
T.Protein
ALP
ALT
35 <20
66 53 <32
Coag.
profile
PT
APTT
INR
10-13.5 sec
26 - 42 sec
<1.5
Cardiac
enzymes
CK
LDH
AAT
24 - 195 u/l
0 - 248 u/l
<37
ABG
pH
pCO2
pO 2
HCO3
O2 sat
7.35-7.45
35-45mmHg
72-100mmHg
22-29mmol/L
90-95%
Others
RBS
< 11 mmol/L
BP
TEMP
RR
PR
12 - 18 b/min
60 - 100 p/min
Appendices
TWBC
Hb
RBC
HCT
Platlet
Day & Date

N.Range
4-11 x10/L
11.5-16.5 g/100mL
4.5-6.3x106
0.4/0.37-0.52/0.48
150-400 x10/L
Vital signs
Appendix 10d
50 g/L
umol/L
87 g/L
141 u/L
u/L
Date
(sampling)
Sources/sample
M/organism
Sensitivity
Resistant
C&S
Date
56
Appendix 10e
10
11
12
13
14
15
16
17
18
19
20
Appendices
Lipid
Date
T. Chol
C-TG
C-HDL
C-LDL
<5.7 mmol/L
<1.7 mmol/L
>1.7mmol/L
<3.9 mmol/L
57
Appendix 10f
DATE
PHARMACEUTICAL CARE ISSUES
PHARMACIST RECOMMENDATION
OUTCOME
Appendices
58
Appendix 10g
PHARMACEUTICAL CARE ISSUES
PHARMACIST RECOMMENDATION
OUTCOME
Appendices
DATE
59
Appendix 10h
DISCHARGE MEDICATION
Appendices
NEXT TCA:
60
Appendix 11a
CLINICAL PHARMACY REPORT FORM
CP3
Pharmacy Department, Hospital ..

A: WARD PHARMACY ACTIVITY
Date :
Ward :
Task : Full Time / Part Time
Physician(s)
:
Routine Rounds
Grand Rounds
Pharmacist Rounds
Number of Cases Clerked
Number of Cases Reviewed
Number of Patients in Ward
Number of Medication History (CP1) Taken
B: INTERVENTIONS / REQUESTS ENCOUNTERED

Interventions
Description
Number of
Number of
interventions
interventions
Request / Information
Number Total
Provided
accepted
(1)
Incomplete
Prescription
Patient data
Adverse Drug Reaction
Drug
Drug Toxicity
Dose
Drug Dosage
Frequency
Therapeutic Efficacy
Duration
Drug Indication
Drs Stamp & Sign
Drug Interaction
Drug
Pharmacokinetic
(2)
Incorrect/
Dose
Inappropriate/
Inadequate Frequency
Duration
Regimen
Polypharmacy
(3)
Inappropriate Contraindication
Prescription Drug Interaction
TPN
General Product Information
Pharmaceutical Availability
Pharmaceutical Compatibility
Pharmaceutical Identification
Incompatibility
Unclear Handwriting
Authenticity of
(4)
Miscellaneous Prescription/
Prescriber
Error
Suggest For Vital
Signs Monitoring/
Laboratory
Investigation
TOTAL INFORMATION
PROVIDED
COUNSELLING
Bedside Counselling
TDM
Discharge Counselling
TPN
Group Counselling
TOTAL INTERVENTIONS
Number Total No.

Of
Of
Sessions Patients
Appendices
Drug Administration
GRAND TOTAL
61
Appendix 11b
C: DESCRIPTION OF REQUESTS / INTERVENTIONS ENCOUNTERED
D: FOLLOW-UP REQUIRED
No
FOLLOW-UP
CHECKLIST
SIGN
Appendices
..
Pharmacist Sign & Stamp
Date:
Pin. 1/10
62
Appendix 12
Appendices
DISCHARGE REFERRAL NOTE
63
Appendix 13
Appendices
64
Appendices
Appendix 14
65
Appendix 15
BORANG LAPORAN ADUAN PRODUK
YANG BERDAFTAR DENGAN PIHAK BERKUASA KAWALAN DADAH
Product Complaint Form for Products Registered with the Drug Control Authority
SILA KEMUKAKAN SAMPEL ADUAN BERSAMA DENGAN BORANG INI

Please send complaint samples with this form
i. MAKLUMAT PRODUK
Particulars of Product
NAMA PRODUK:
Name of Product
NO. PENDAFTARAN PBKD/MAL:
NO. KELOMPOK:
Registration Number
Batch Number
TARIKH DIKILANGKAN:
TARIKH LUPUT:
Manufacturing Date
Expiry Date
ii. BUTIR-BUTIR ADUAN LENGKAP

Sila isikan bahagian yang berkenaan
Please fill in the details according to the nature of the complaint
ADUAN KUALITI:
Complaint on product quality
....................................................
ADUAN EFIKASI:
Complaint on product efficacy
Bagi masalah efikasi, kerjasama tuan/puan diminta supaya memberi maklumbalas objektif seperti:- % pesakit yang menghadapi masalah
- Adakah masalah berlaku selepas brand switching
- Objective findings seperti BP reading, RBS dll yang boleh menyokong aduan bahawa produk
kurang berkesan.
Kindly provide us with objective feedback such as:
- % patients having similar problems
- Was the problem occurring after brand switching
- Objective findings such as BP reading, RBS etc to support the complaint on the efficacy of the product
.........
.
...........................
iii. MAKLUMAT PELAPOR
Particulars of Complainant
NAMA:
JAWATAN/PEKERJAAN:
Name
Designation/Occupation
ALAMAT LENGKAP TEMPAT KERJA:

Address
Appendices
TELEFON:
FAX:
Telephone
Fax
TANDATANGAN:
Signature
Sila hantar kepada:

Please send to:
66
TARIKH:
Date
SEKSYEN SURVEILANS & ADUAN PRODUK
PUSAT PASCA PENDAFTARAN PRODUK
BIRO PENGAWALAN FARMASEUTIKAL KEBANGSAAN
KEMENTERIAN KESIHATAN MALAYSIA
JALAN UNIVERSITI, PETI SURAT 319
46730 PETALING JAYA
Fax: 603-79567151
8.0
GLOSSARY
Dose regimen - A complete information on name of drug, mode of administration,

dosage, frequency and duration
2.
Compliance aid - Any device such as pillbox, pamphlet or timetable guide that
helps to improve the patient's compliance to medication
3.
Pharmaceutical Care issue (PCI) - Any problems related to patients' diseases

and drug treatment conditions
4.
Single Ward - Only one individual ward
5.
Counseling - A professional relationship and activity through which a pharmacist

endeavours to educate patients on their pharmacotherapy and enhance
compliance to medications by giving professional advice, opinion and instructions.
6.
Bedside counseling - Counseling given to patient who is in the ward
7.
Discharge counseling - Counseling given to patient upon discharge
8.
Group counselling - Counseling given to a group of patient who has similarity in

disease state
9.
QAP - Quality assurance programme
10.
PF - Pengurusan Farmasi is an indicator for monitoring the workload and

performance of the activities in the pharmacy services.
11.
Routine round - Daily ward round between the ward pharmacists, medical officer
with or without the specialist or consultant.
12.
Grand round - Scheduled departmental round participated by the ward pharmacists

with the consultants, specialist, medical officer and nursing staff.
13.
Pharmacists round - Pharmacotherapy ward round involving the ward pharmacist

with other fellow pharmacists.
14.
No. of cases clerked - Cases clerked for the first time during the current admission
15.
No. of cases reviewed - Clerked cases that are reviewed on the following days
16.
Chief complaints (CC) - Main complaints made by the patients during admission. It
should be documented as layman term
Glossary
1.
67
17.
History of present illness (HPI)
Presenting symptoms and time scale of their occurrence

Date of presentation to hospital or clinic
Mode of admission eg. Acute emergency or referral
18.
Past medical history (PmHx)

Past medical problems listed, emphasizing those relevant to the case and
with attention to accurate sequence and timing of events including previous
admissions to hospital and specialist referrals
19.
Social history (SHx)

Smoking and alcohol habits, social circumstances including social & family
support
Unusual living conditions, travel or habits where these may be relevant to the
patient's medical condition
20.
Family history (FHx)
Relevant familial illness especially premature deaths of parents or siblings

21.
FUKKM - Formulasi Ubat, Kementerian Kesihatan Malaysia is a list of a drug

formulary under Ministry of Health
22.
Health Facility - Hospital, Health Clinic and Health Institution under Ministry of
Health
23.
Second Copy - a referral letter that is used to refer patient from one facility to
another
24.
LP form - Local Purchase Form
25.
DOA - Date of Admission
26.
TDM - Therapeutic Drug Monitoring
Glossary
68

Guidelines Inpatient Pharmacy Practice

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Guidelines Inpatient Pharmacy Practice

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PHARMA

MINISTRY OF HEALTH MALAYSIA

First Print, 2010

ALL RIGHTS RESERVED

Perpustakaan Negara Malaysia

Hasnah binti Ismail

1.0 Inpatient Pharmacy Services

2.0 Drug Distribution Activities

Unit Dose System

3.0 Ward Pharmacy Activities

Medication History Taking

4.0 Other Activities

Clinical Pharmacokinetic Service

INPATIENT PHARMACY SERVICES

DRUG DISTRIBUTION ACTIVITIES

To avoid occurence of medication error

iii. To minimise drug wastage

To maintain information on drug utilization and rational drug use

vi. To identify unusual patterns of drug usage

Drug Distribution Method

After Office Hours Supply

iii. Supply For Psychotropic Medicines

Ward / Unit Inspection

UNIT DOSE SYSTEM

Handling of Medication Trolley

1. The medication trolley should be sent to the pharmacy by the nurse

8. The completed original prescription must be separated from the

Receiving the Prescription

5. All new prescriptions which have been screened should be pasted

Tab. Allopurinol 300mg

6. To discontinue a medication, the prescription at the CMR must be

4. Amount of medication and frequency supplied for the day should be

5. Pharmacy staff has to ensure the cleanliness of the medication trolley

6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am

6 am, 12 noon, 6 pm, 10 pm

6 am (before breakfast), 6 pm (before dinner)

Placed at the furthest end of the patient's bin.

TELAH DIBEKAL PADA

9. Filling of prescriptions involving psychotropic medications,

8. For the dispensing of medications such as eye/ear drop solutions or

Example 2: Tab. Chlorpheniramine 4mg TDS & PRN

Checking the Supply (Countercheck)

FLOOR STOCK / EMERGENCY TROLLEY MEDICATIONS

Wards are only permitted to keep a limited quantity of frequently-used medications. A

4. Supply medication according to the recorded quantity

AFTER OFFICE HOURS SUPPLY

SUPPLY OF PSYCHOTROPIC MEDICINES

SUPPLIES FOR DISCHARGED PATIENTS

4. Patients on medications with narrow therapeutic index.

HANDLING REFERRAL LETTER (SECOND COPY) AND SUPPLY OF

To ensure preparedness of medications at the referred facility

To ensure continuity of treatment

Referring patient by referring facility

The second copy is to be given to the Pharmacist at the

The third copy is to be kept in patient file at the referring facility

2. Pharmacist at the referring facility will review the patient's drug

Both Pharmacists should also discuss the patient's next supply

Receiving Second Copy at referred facility

WARD / UNIT INSPECTION

Ward Inspection is done to ensure the following:

Medication trolleys are checked regularly

g. Refrigerated items are stored appropriately

Criteria for Good Drug Distribution Service

Implementing the Unit Dose System