Filled Out by: Date: Reviewed / Approval for Action By: Date: L1 Review - Multiple Patient Form Task: MISC. / DUPLICATE / OBSOLETE / COMPLIANCE CHECK / MISALIGNMENT / DOSE DIRECTIONS / SYNCHRONISATION / EXTERNAL ISSUE / CMS Form Filled Out by:……………………………………………………………. Date:……………………… Form Reviewed by:……………………………………………….. Date:…………………………. Patient Name Pt ID / CHI / DOB Drug Detail(s) and Proposed Action Agreed Action Communicate Complete? Recorded Completed Change in PMR? Initials Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action Remove Patient Amend as Agreed Yes Yes Pharmacy No Action
Filled Out by: Date: Reviewed / Approval for Action By: Date: L1 Review - Multiple Patient Form Task: MISC. / DUPLICATE / OBSOLETE / COMPLIANCE CHECK / MISALIGNMENT / DOSE DIRECTIONS / SYNCHRONISATION / EXTERNAL ISSUE / CMS Form Filled Out by:……………………………………………………………. Date:……………………… Form Reviewed by:……………………………………………….. Date:…………………………. Patient Name Pt ID / CHI / DOB Drug Detail(s) and Proposed Action Agreed Action Communicate Change Complete? Recorded in PMR? Completed Initials Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes Remove Amend as Agreed No Action Patient Pharmacy Yes Yes