5.8 KiB
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