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# Pediatric Pharmacy Competency Assessment
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| Document ID | FRM-004 |
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| Title | Pediatric Pharmacy Competency Assessment |
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| Revision | 1.0 |
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| Effective Date | [DATE] |
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---
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## Employee Information
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| Field | Value |
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|-------|-------|
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| Employee Name | ________________________________ |
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| Position | ☐ Pediatric Pharmacist ☐ Pharmacy Technician ☐ Pharmacy Resident ☐ Student |
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| License/Registration # | ________________________________ |
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| Hire Date | ________________________________ |
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| Assessment Date | ________________________________ |
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| Assessment Type | ☐ Initial ☐ Annual ☐ Triggered ☐ Return from leave |
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## Assessor Information
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| Field | Value |
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|-------|-------|
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| Assessor Name | ________________________________ |
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| Title | ________________________________ |
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| License # | ________________________________ |
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| Date | ________________________________ |
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---
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## Part 1: Pediatric Dosing Calculations
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**Instructions:** Complete all calculations. 100% accuracy required. Show all work.
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### Scenario 1: Weight-Based Dosing
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**Patient:** 3-year-old male, weight 14.2 kg
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**Order:** Amoxicillin 40 mg/kg/day divided every 8 hours
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**Questions:**
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1. Calculate total daily dose: ____________ mg/day
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2. Calculate individual dose: ____________ mg per dose
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3. Is this dose within the recommended range for amoxicillin (20-90 mg/kg/day)? ☐ Yes ☐ No
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**Work shown:**
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_____________________________________________________________________
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_____________________________________________________________________
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### Scenario 2: Maximum Dose Application
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**Patient:** 12-year-old female, weight 52 kg
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**Order:** Ondansetron 0.15 mg/kg IV for nausea
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**Questions:**
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1. Calculate dose based on weight: ____________ mg
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2. Maximum dose for ondansetron is 16 mg. What dose would you dispense? ____________ mg
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3. Why? _____________________________________________________________
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**Work shown:**
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_____________________________________________________________________
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_____________________________________________________________________
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### Scenario 3: BSA-Based Dosing
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**Patient:** 7-year-old male, weight 25 kg, height 120 cm, BSA 0.92 m²
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**Order:** Vincristine 1.5 mg/m² IV (chemotherapy)
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**Questions:**
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1. Calculate dose: ____________ mg
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2. This dose will be independently verified by a second pharmacist because:
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☐ High-alert medication
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☐ Chemotherapy
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☐ Both
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☐ Neither
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**Work shown:**
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_____________________________________________________________________
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_____________________________________________________________________
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### Scenario 4: Neonatal Dosing
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**Patient:** Premature infant, gestational age 32 weeks, postnatal age 5 days, weight 1.8 kg
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**Order:** Gentamicin 4 mg/kg/dose IV every 24 hours
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**Questions:**
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1. Calculate dose: ____________ mg
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2. For a 10 mg/mL concentration, what volume is needed? ____________ mL
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3. Does the extended interval (q24h) make sense for this patient? ☐ Yes ☐ No
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Why? ____________________________________________________________
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**Work shown:**
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_____________________________________________________________________
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_____________________________________________________________________
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### Scenario 5: Dilution Calculation
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**Patient:** 6-month-old infant, weight 7.5 kg
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**Order:** Digoxin 10 mcg/kg/day divided BID
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**Available:** Digoxin elixir 50 mcg/mL
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**Questions:**
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1. Total daily dose: ____________ mcg/day
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2. Individual dose: ____________ mcg per dose
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3. Volume to administer per dose: ____________ mL
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**Work shown:**
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_____________________________________________________________________
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_____________________________________________________________________
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---
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## Part 2: Knowledge Assessment
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**Instructions:** Answer all questions.
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### 1. Pediatric Age Categories
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Match the age to the correct category:
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| Age | Category |
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|-----|----------|
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| 2 months | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
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| 15 days | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
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| 5 years | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
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| 16 years | ☐ Neonate ☐ Infant ☐ Child ☐ Adolescent |
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### 2. High-Alert Medications
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List 5 high-alert medications in pediatrics that require independent double-check:
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1. _________________________________
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2. _________________________________
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3. _________________________________
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4. _________________________________
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5. _________________________________
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### 3. Weight Currency
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What is the maximum age of weight for the following patient types?
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- NICU/critical care inpatients: ☐ 24 hours ☐ 72 hours ☐ 1 week
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- General inpatients: ☐ 24 hours ☐ 72 hours ☐ 1 week
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- Outpatient infants (<1 year): ☐ 1 month ☐ 3 months ☐ 6 months
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### 4. USP Standards
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Which USP chapter covers non-sterile compounding?
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☐ USP <795>
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☐ USP <797>
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☐ USP <800>
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Which USP chapter covers sterile compounding?
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☐ USP <795>
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☐ USP <797>
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☐ USP <800>
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### 5. Off-Label Use
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Approximately what percentage of medications used in pediatrics are off-label?
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☐ <10%
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☐ 25-30%
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☐ 50-70%
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☐ >90%
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---
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## Part 3: Practical Skills Assessment
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**Instructions:** Assessor observes and evaluates performance.
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### Skill 1: Order Verification and Dosing
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**Task:** Process a pediatric medication order from start to finish
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| Step | Satisfactory | Needs Improvement | Not Observed |
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|------|--------------|-------------------|--------------|
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| Verifies patient identity (name, DOB, MRN) | ☐ | ☐ | ☐ |
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| Obtains current patient weight | ☐ | ☐ | ☐ |
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| Verifies weight is current per policy | ☐ | ☐ | ☐ |
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| Calculates dose accurately | ☐ | ☐ | ☐ |
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| Checks dose against reference range | ☐ | ☐ | ☐ |
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| Verifies maximum dose not exceeded | ☐ | ☐ | ☐ |
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| Documents calculation appropriately | ☐ | ☐ | ☐ |
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| Obtains independent verification if required | ☐ | ☐ | ☐ |
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| Selects age-appropriate formulation | ☐ | ☐ | ☐ |
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**Overall Performance:** ☐ Competent ☐ Needs additional training
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**Comments:** ___________________________________________________________
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### Skill 2: Compounding Oral Suspension (if applicable)
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**Task:** Compound an oral suspension from tablets following SOP
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| Step | Satisfactory | Needs Improvement | Not Observed |
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|------|--------------|-------------------|--------------|
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| Performs calculations correctly | ☐ | ☐ | ☐ |
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| Prepares workspace appropriately | ☐ | ☐ | ☐ |
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| Uses proper hand hygiene and garbing | ☐ | ☐ | ☐ |
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| Crushes tablets to fine powder | ☐ | ☐ | ☐ |
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| Uses geometric dilution correctly | ☐ | ☐ | ☐ |
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| Achieves smooth, uniform suspension | ☐ | ☐ | ☐ |
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| Brings to accurate final volume | ☐ | ☐ | ☐ |
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| Labels correctly with all required info | ☐ | ☐ | ☐ |
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| Assigns appropriate BUD | ☐ | ☐ | ☐ |
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| Documents in compounding log | ☐ | ☐ | ☐ |
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**Overall Performance:** ☐ Competent ☐ Needs additional training
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**Comments:** ___________________________________________________________
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### Skill 3: Patient/Family Counseling
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**Task:** Counsel parent/guardian on pediatric medication
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| Step | Satisfactory | Needs Improvement | Not Observed |
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|------|--------------|-------------------|--------------|
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| Introduces self and confirms patient | ☐ | ☐ | ☐ |
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| Uses age-appropriate language | ☐ | ☐ | ☐ |
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| Explains indication for medication | ☐ | ☐ | ☐ |
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| Demonstrates dose measurement | ☐ | ☐ | ☐ |
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| Emphasizes importance of accurate dosing | ☐ | ☐ | ☐ |
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| Explains administration technique | ☐ | ☐ | ☐ |
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| Reviews storage requirements | ☐ | ☐ | ☐ |
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| Discusses common side effects | ☐ | ☐ | ☐ |
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| Emphasizes completing full course | ☐ | ☐ | ☐ |
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| Provides opportunity for questions | ☐ | ☐ | ☐ |
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**Overall Performance:** ☐ Competent ☐ Needs additional training
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**Comments:** ___________________________________________________________
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---
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## Part 4: Scenario-Based Assessment
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### Scenario: Potential Error Identification
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**Situation:** A 2-month-old infant (4.5 kg) has an order for gentamicin 15 mg IV every 8 hours.
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**Usual neonatal dosing:** 4-5 mg/kg/dose every 24-48 hours (extended interval)
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**Questions:**
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1. Do you see any concerns with this order? ☐ Yes ☐ No
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2. If yes, what are they?
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_________________________________________________________________
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_________________________________________________________________
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3. What action would you take?
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☐ Dispense as ordered
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☐ Contact prescriber for clarification
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☐ Refuse to fill
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☐ Other: __________
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4. Calculate what the dose should likely be:
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_________________________________________________________________
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**Assessor evaluation:**
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☐ Correctly identified potential error
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☐ Appropriate action plan
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☐ Accurate alternative dose calculation
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---
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## Assessment Results
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### Part 1: Dosing Calculations
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- Scenarios correct: ______ / 5
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- **Required: 5/5 (100%)**
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- Result: ☐ **PASS** ☐ **FAIL**
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### Part 2: Knowledge Assessment
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- Questions correct: ______ / 9
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- **Required: 7/9 (78%)**
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- Result: ☐ **PASS** ☐ **FAIL**
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### Part 3: Practical Skills
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- Skills demonstrated competently: ______ / 3
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- **Required: 3/3**
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- Result: ☐ **PASS** ☐ **FAIL**
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### Part 4: Scenario Assessment
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- Result: ☐ **PASS** ☐ **FAIL**
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---
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## Overall Assessment Result
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☐ **COMPETENT** - All sections passed, authorized for independent practice
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☐ **NEEDS REMEDIATION** - See below for areas needing improvement
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☐ **NOT COMPETENT** - Requires additional training before reassessment
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### Areas Needing Improvement:
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_____________________________________________________________________
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_____________________________________________________________________
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_____________________________________________________________________
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### Remediation Plan:
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_____________________________________________________________________
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_____________________________________________________________________
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_____________________________________________________________________
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**Reassessment Date:** ____________________
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---
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## Signatures
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### Employee
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I have completed this competency assessment to the best of my ability.
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**Signature:** _________________________ **Date:** __________
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### Assessor
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I have assessed this employee's competency in pediatric pharmacy practice.
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**Signature:** _________________________ **Date:** __________
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**Printed Name:** _________________________ **License #:** __________
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### Pharmacy Manager (if remediation required)
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**Signature:** _________________________ **Date:** __________
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---
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**Record Retention:** Maintained in employee file per regulatory requirements
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**Next Assessment Due:** ____________________
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---
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*Form FRM-004 Rev 1.0 - Pediatric Pharmacy*
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