# 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

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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## Disposition
☐ Dose verified and approved - proceed with dispensing
☐ Contacted prescriber for clarification
☐ Order modified per prescriber
☐ Order discontinued

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**For Pharmacy Use Only**

Calculation reviewed by: _____________ Date: ________ Time: ________

Filed in: ☐ Patient chart ☐ Pharmacy records ☐ Both

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*Form FRM-DOSE-001 Rev 1.0 - Pediatric Pharmacy*