Per JCAHO, an ADR is an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity or both.

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When you click 'Submit' an email of the information will be sent to you.
Hospice Name (*)
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Date (*)
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Patient Initials (*)
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Patient ID Number (*)
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Physician Name (*)
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Physician Phone Number (*)
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Primary Nurse Name (*)
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Nurse Telephone Number (*)
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Medication Name, Route and Dose (*)
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Description of ADR (*)
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Did the ADR require medical treatment? (*)
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If Yes, above, please describe medical treatment of ADR
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Was the ADR submitted to Med Watch? (*)
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