Sync template from atomicqms-style deployment

Forms/Dose-Calculation/FRM-DOSE-001-Pediatric-Dose-Calculation-Worksheet.md

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+# Pediatric Dose Calculation Worksheet
+
+| Document ID | FRM-DOSE-001 |
+|-------------|--------------|
+| Title | Pediatric Dose Calculation Worksheet |
+| Revision | 1.0 |
+| Effective Date | [DATE] |
+
+---
+
+## Patient Information
+
+| Field | Value |
+|-------|-------|
+| Patient Name | _________________________ |
+| Date of Birth | _________________________ |
+| Age | _________________________ |
+| Medical Record # | _________________________ |
+| Date/Time of Calculation | _________________________ |
+
+## Patient Measurements
+
+| Measurement | Value | Date/Time Obtained | Source |
+|-------------|-------|-------------------|---------|
+| Weight (kg) | _________ kg | _____________ | ☐ Inpatient chart ☐ Outpatient ☐ Parent-reported |
+| Height (cm) | _________ cm | _____________ | ☐ Inpatient chart ☐ Outpatient ☐ Parent-reported |
+| BSA (m²) | _________ m² | _____________ | Calculation method: ☐ Mosteller ☐ DuBois ☐ Other: _____ |
+
+**Weight Status:**
+☐ Current per policy (specify timeframe): _____________
+☐ Needs update - contacted: ☐ Nurse ☐ Clinic ☐ Parent
+
+## Medication Order
+
+| Field | Value |
+|-------|-------|
+| Medication | _________________________________________ |
+| Indication | _________________________________________ |
+| Ordered Dose | _________________________________________ |
+| Dosing Frequency | _________________________________________ |
+| Route | _________________________________________ |
+| Prescriber | _________________________________________ |
+
+## Dose Calculation
+
+### Dosing Type
+☐ Weight-based (mg/kg)
+☐ BSA-based (mg/m²)
+☐ Fixed dose (no calculation needed)
+☐ Other: _______________
+
+### Calculation Method
+
+**If Weight-Based:**
+```
+Dose ordered: ________ mg/kg/dose  OR  ________ mg/kg/day
+
+Calculation:
+_______ kg × _______ mg/kg/dose = _______ mg/dose
+
+OR (if total daily dose):
+_______ kg × _______ mg/kg/day = _______ mg/day
+_______ mg/day ÷ _______ doses/day = _______ mg/dose
+```
+
+**If BSA-Based:**
+```
+Dose ordered: ________ mg/m²/dose  OR  ________ mg/m²/day
+
+Calculation:
+_______ m² × _______ mg/m²/dose = _______ mg/dose
+
+OR (if total daily dose):
+_______ m² × _______ mg/m²/day = _______ mg/day
+_______ mg/day ÷ _______ doses/day = _______ mg/dose
+```
+
+### Final Dose
+**Calculated Dose:** __________ mg/dose
+
+**Rounded/Dispensed Dose:** __________ mg/dose
+
+**Reason for rounding (if applicable):**
+☐ Available dosage form
+☐ Measurable quantity
+☐ Patient-specific factors
+☐ Other: _______________________
+
+## Dose Verification
+
+### Reference Check
+**Reference Source(s):** ☐ Lexicomp ☐ Micromedex ☐ Harriet Lane ☐ Neofax ☐ Other: __________
+
+**Recommended Dosing Range for Indication:**
+- Minimum: __________ mg/kg/dose (or mg/m²/dose)
+- Maximum: __________ mg/kg/dose (or mg/m²/dose)
+- Frequency: __________
+
+**Calculated dose within range?** ☐ Yes ☐ No
+
+**If NO, action taken:**
+☐ Clarified with prescriber (see notes)
+☐ Clinical justification documented
+☐ Order discontinued
+☐ Other: _______________________
+
+### Maximum Dose Check
+**Maximum dose per dose:** __________ mg (if applicable)
+**Maximum dose per day:** __________ mg (if applicable)
+
+**Does calculated dose exceed maximum?** ☐ Yes ☐ No ☐ N/A
+
+**If YES, dispensed dose:** __________ mg (maximum dose applied)
+
+### Age-Specific Considerations
+☐ Dose appropriate for patient age
+☐ Formulation appropriate for patient age/development
+☐ No age-specific contraindications
+☐ Age-specific warnings reviewed
+
+### Special Populations
+☐ Renal adjustment needed - CrCl: _____ mL/min - Adjusted dose: _____ mg
+☐ Hepatic adjustment needed - Severity: _____ - Adjusted dose: _____ mg
+☐ Obese (>95th percentile) - Used: ☐ Actual weight ☐ Ideal weight ☐ Adjusted weight
+☐ Premature infant - Gestational age: _____ weeks - PMA: _____ weeks
+
+## High-Alert Medication Independent Double-Check
+
+**Is this a high-alert medication?** ☐ Yes ☐ No
+
+**If YES, complete independent verification:**
+
+### First Pharmacist Calculation
+- Pharmacist Name: _________________________ Date/Time: _________
+- Calculated Dose: __________ mg/dose
+- Within Range: ☐ Yes ☐ No
+- Signature: _________________________
+
+### Second Pharmacist Independent Calculation
+- Pharmacist Name: _________________________ Date/Time: _________
+- Calculated Dose: __________ mg/dose
+- Within Range: ☐ Yes ☐ No
+- Signature: _________________________
+
+### Verification Result
+☐ Calculations match - Proceed
+☐ Discrepancy identified - see resolution below
+
+**Discrepancy Resolution:**
+_________________________________________________________________
+_________________________________________________________________
+
+## Final Verification and Approval
+
+**Final Dose to Dispense:** __________ mg per dose
+**Quantity to Dispense:** __________ (doses/volume)
+**Dosing Instructions:** _______________________________________________
+
+**Off-Label Use?** ☐ Yes ☐ No
+**If YES, clinical justification:** _____________________________________
+
+**Pharmacist Final Verification:**
+- Name: _________________________
+- License #: _________________________
+- Signature: _________________________
+- Date/Time: _________________________
+
+## Notes/Comments
+
+_____________________________________________________________________
+_____________________________________________________________________
+_____________________________________________________________________
+_____________________________________________________________________
+
+---
+
+## Disposition
+☐ Dose verified and approved - proceed with dispensing
+☐ Contacted prescriber for clarification
+☐ Order modified per prescriber
+☐ Order discontinued
+
+---
+
+**For Pharmacy Use Only**
+
+Calculation reviewed by: _____________ Date: ________ Time: ________
+
+Filed in: ☐ Patient chart ☐ Pharmacy records ☐ Both
+
+---
+
+*Form FRM-DOSE-001 Rev 1.0 - Pediatric Pharmacy*