Slidell Memorial Hospital
SMH Medication Formulary
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Slidell Memorial Hospital
SMH Medication Formulary
Go to DRUG IDENTIFIER
FormWeb Users Guide
Questions or Suggestions?
Search by name
Additional search options
Search by class
Browse alphabetically
Select...
NUM
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
High Alert
Black Box Warning
REMS
Sound Alike/Look Alike Drugs
Order Sets / Dosing Tools
Automatic Therapeutic Substitutions
Webpage Links
ADR Report Form (1)
ADR Report Form
An ADR is any untoward reaction which is associated with drug therapy and requires treatment with prescription medication, results in or prolongs patient hospitalization, results in permanent or temporary disability, results in patient death or requires reporting to FDA.
Please enter the following information:
*
Denotes Required Fields
* Patient Name:
* Medical Record
Number:
* Date of Birth
(MM/DD/YYYY):
or age
* Patient Location:
* Patient Gender
Male
Female
* Service:
* Report Date
:
* Date of ADR:
* Reporter Initials:
* Reporter
Profession:
Choose One
MD
RN
RPh
RT
Other
* Suspected
Drug(s):
* Drug Class:
Manufacturer:(optional)
* Prior Exposure:
Yes
No
* Dose:
* Route:
* Start Date:
* Stop Date:
* Number of Doses:
* Describe Reaction:
* Concomitant
Drugs:
* Treatment of ADR:
* Relevant Lab
Tests / Medical
History:
* ADR Outcome:
(check all that apply)
01 Symptoms resolved or improved
02 Required treatment with Rx drug
03 Resulted in hospitalization
04 Prolonged hospitalization
05 Patient death
06 None of the above, required no therapy
07 Other
* Action Taken:
(check all that apply)
01 Drug discontinued
02 Drug continued
03 Dosage reduced
04 Patient counseled
