# Pediatric Oral Suspension Compounding Log

| Document ID | FRM-COMP-001 |
|-------------|--------------|
| Title | Oral Suspension Compounding Log |
| Revision | 1.0 |
| Effective Date | [DATE] |

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## Patient/Prescription Information

| Field | Value |
|-------|-------|
| Patient Name | ________________________________ |
| Date of Birth | ________________________________ |
| Prescription Number | ________________________________ |
| Prescriber | ________________________________ |
| Date Compounded | ________________________________ |

## Formulation Information

| Field | Value |
|-------|-------|
| Medication | ________________________________ |
| Final Concentration | _________ mg/mL (or mcg/mL) |
| Total Volume | _________ mL |
| Flavor | _________ ☐ None |
| Beyond-Use Date (BUD) | ________________________________ |
| Storage Requirements | ☐ Refrigerate (2-8°C) ☐ Room temperature ☐ Protect from light |

## Calculations

### Dosage Form Used
☐ Tablets
☐ Capsules
☐ Bulk powder

**Product Details:**
- Manufacturer: _______________________
- Strength: _________ mg per tablet/capsule
- NDC: _______________________
- Lot Number: _______________________
- Expiration Date: _______________________

### Quantity Calculation

**Quantity Needed:**
```
Desired concentration: _______ mg/mL
Final volume needed: _______ mL
Total drug needed: _______ mL × _______ mg/mL = _______ mg total
```

**Dosage Forms Required:**
```
_______ mg total ÷ _______ mg per unit = _______ units

Round up to: _______ tablets/capsules
(includes overage: ______ %)
```

**Verified by:** _________________ (Second pharmacist initials)

## Ingredients

| Ingredient | Manufacturer/Brand | Lot Number | Expiration Date | Quantity Used |
|------------|-------------------|------------|-----------------|---------------|
| [Drug name] | _______________ | __________ | ______________ | ______ units |
| Suspending vehicle | _______________ | __________ | ______________ | ______ mL |
| Sweetening agent | _______________ | __________ | ______________ | ______ mL |
| Flavoring (if used) | _______________ | __________ | ______________ | ______ mL |
| Other: __________ | _______________ | __________ | ______________ | __________ |

## Compounding Procedure

### Preparation Checklist
☐ Hand hygiene performed
☐ Appropriate garbing (lab coat, gloves)
☐ Work area cleaned and disinfected
☐ Equipment cleaned and ready
☐ All ingredients verified and gathered

### Compounding Steps Completed

☐ **Step 1:** Counted and verified ______ tablets/capsules
☐ **Step 2:** Crushed tablets to fine powder / Emptied capsule contents
☐ **Step 3:** Triturated to uniform powder
☐ **Step 4:** Added small portion of vehicle, mixed to smooth paste
☐ **Step 5:** Used geometric dilution, added vehicle in portions
☐ **Step 6:** Transferred to graduated cylinder
☐ **Step 7:** Rinsed mortar with vehicle
☐ **Step 8:** Brought to final volume: _______ mL
☐ **Step 9:** Added flavor (if applicable): _______ mL
☐ **Step 10:** Transferred to final container
☐ **Step 11:** Shook thoroughly for 30 seconds

## Quality Control

### Visual Inspection
☐ Uniform suspension (no large particles)
☐ Appropriate color
☐ Smooth consistency
☐ No visible contamination
☐ Suspends well when shaken

### Volume Verification
- Target volume: _______ mL
- Actual volume: _______ mL
- Within acceptable range (±5%): ☐ Yes ☐ No

### Concentration Verification
```
Total drug: _______ mg
Final volume: _______ mL
Concentration: _______ mg ÷ _______ mL = _______ mg/mL
```
☐ Matches intended concentration

**Independent calculation by:** _________________ (Pharmacist initials)

## Beyond-Use Date Determination

**Stability Reference:**
☐ Published study (citation): _________________________________
☐ USP <795> general guidance: 14 days refrigerated / 30 days room temp
☐ Manufacturer information
☐ Trissel's Stability Reference
☐ Other: _________________________________

**BUD Assigned:** _________________________________

**Rationale:** ___________________________________________________

## Labeling

☐ Patient name and date of birth
☐ Medication name and concentration
☐ "SHAKE WELL BEFORE EACH USE"
☐ Directions for use
☐ Beyond-use date
☐ Storage instructions
☐ "For Oral Use Only"
☐ Flavor (if added)
☐ Pharmacist initials
☐ Compounding date
☐ Auxiliary labels (if applicable)

**Oral syringe provided:** ☐ Yes (size: _____ mL) ☐ No ☐ N/A

## Final Verification

### Pharmacist Final Check
☐ Correct medication and strength
☐ Accurate calculations verified
☐ Appropriate concentration for patient
☐ Correct labeling
☐ BUD appropriate and documented
☐ Storage instructions clear
☐ Quality checks passed

**Verifying Pharmacist:**
- Name: _________________________
- License #: _________________________
- Signature: _________________________
- Date/Time: _________________________

## Counseling Points Provided

☐ Shake well before each use
☐ Use oral syringe for accurate dosing
☐ Storage requirements explained
☐ Beyond-use date explained
☐ Administration technique demonstrated
☐ Side effects discussed
☐ Importance of completing therapy

**Counseled by:** __________________ Date/Time: __________

## Documentation

### Compounded by
- Technician/Pharmacist Name: _________________________
- Signature: _________________________
- Date/Time: _________________________

### Checked by
- Pharmacist Name: _________________________
- License #: _________________________
- Signature: _________________________
- Date/Time: _________________________

## Cleanup

☐ All equipment washed and dried
☐ Work surface disinfected
☐ Waste disposed of appropriately
☐ Ingredients returned to storage

**Cleaned by:** __________________ Date/Time: __________

## Notes/Deviations

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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## For Pharmacy Records

**Record Retention:** Per state board requirements (minimum 3 years)

**Filed in:** ☐ Compounding logs ☐ Patient profile ☐ Both

**Log reviewed by:** ______________ Date: ________

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*Form FRM-COMP-001 Rev 1.0 - Pediatric Pharmacy Compounding*