Renal/Hepatic Dose Adjustment Note

Date/Time: [Date and time of note entry]

Author: [Name, credentials (PharmD / MD / DO / APP), service/team]

Patient: [Patient identifier per local policy]

Location/Encounter: [Unit / clinic / ED / inpatient / outpatient]

Reason for Dose Adjustment Review

[Trigger for review in 1–2 sentences, including requestor if consult-driven]

Medications Reviewed

(List only medications being adjusted plus key interacting agents that materially affect clearance or toxicity. Do not reproduce the full medication list. If start dates or administration times are unavailable, explicitly state "not documented.")

• [Medication generic name] — [Indication / suspected indication]. Regimen: [Dose, route, frequency]. Therapy start: [Date / not documented]. Last administration: [Time / not documented]. Relevant interacting agents: [Agent and relevance (e.g., nephrotoxin, CYP inhibitor) / none]
• [Medication generic name] — [Indication / suspected indication]. Regimen: [Dose, route, frequency]. Therapy start: [Date / not documented]. Last administration: [Time / not documented]. Relevant interacting agents: [Agent and relevance / none]

Patient Factors & Supporting Data

(Include renal data, hepatic data, or both depending on which organ dysfunction applies. Provide timestamps for all labs; if unavailable, state "timing not specified.")

Renal Function

• Serum creatinine: [Value, units] at [Timestamp]; Trajectory: [stable / rising / falling] [over timeframe if known]
• eGFR (lab-reported): [Value, units] at [Timestamp]
• Renal function used for drug dosing: [Estimated CrCl / eGFR converted to mL/min / measured CrCl or GFR]; Method: [Equation used]; Weight: [actual / ideal / adjusted] [Value]
• Anthropometrics: Height [Value]; Weight [Value] (Include IBW/ABW if used in calculations)
• Renal replacement therapy: [none / IHD / PD / CRRT / SLED]. (If CRRT: Modality: [CVVH / CVVHD / CVVHDF]; Effluent rate: [mL/kg/hr or L/hr])
• Stability statement: [Renal function appears stable / changing / rapidly changing—provide conditional recommendations pending updated labs if unstable or data outdated]

Hepatic Function

• Liver injury markers: AST [Value] at [Timestamp]; ALT [Value] at [Timestamp]; Alk phos [Value] at [Timestamp]; Total bilirubin [Value] at [Timestamp]; Direct bilirubin [Value] at [Timestamp]
• Synthetic function: Albumin [Value] at [Timestamp]; INR [Value] at [Timestamp]
• Hepatic classification for dosing: [Child-Pugh A / B / C / unable to determine—state missing elements]. (If assigned, include component values: bilirubin [Value], albumin [Value], INR [Value], ascites [none / mild / moderate-severe], encephalopathy [grade]. If using institutional definition, name it explicitly.)

Other Patient Factors

(Include only if materially affecting dosing decision)

• [Relevant factors: age extremes, frailty, cachexia/amputations affecting creatinine generation, hemodynamic instability, recent drug toxicities, key drug-drug interactions / none]

Medication Assessment & Recommendation

(Repeat for each medication requiring assessment. Do not infer indication, dialysis modality, or hepatic class without supporting information—label as "likely" with rationale if suspected.)

[Medication generic name]: [Indication]

Current regimen: [Dose, route, frequency]

Clinical question: [Renal adjustment needed? / Hepatic adjustment needed? / Contraindicated at current organ function? / RRT removal requiring supplemental dosing?]

Assessment: [Brief narrative: which organ dysfunction applies, dosing metric/classification used, why adjustment is needed (accumulation risk, reduced clearance, labeling guidance), risk tradeoff between toxicity if unadjusted vs undertreatment if overly reduced]

Recommendation: [Specific action: change to new regimen with dose/route/frequency / hold / avoid and switch to alternative / continue current dose with rationale]. (Include: start timing, dialysis-specific instructions if applicable, max daily dose if relevant, loading dose unchanged if applicable. If multiple acceptable options, present primary and alternative with decision criteria.)

Reference: [Product labeling / institutional protocol / stewardship guideline / primary literature citation]

[Medication generic name]: [Indication]

Current regimen: [Dose, route, frequency]

Clinical question: [Specify question]

Assessment: [Brief narrative]

Recommendation: [Specific action with timing and dialysis instructions if applicable]

Reference: [Source]

Monitoring & Follow-Up

• Laboratory monitoring: [Tests]; Frequency: [Timing]; Reassessment triggers: [Specific thresholds, e.g., SCr increase ≥ X mg/dL, eGFR below Y]
• Clinical monitoring: [Drug-specific toxicity signs to monitor]; Action thresholds: [When to hold/adjust]
• Therapeutic drug monitoring: [Level type (peak / trough / AUC)]; Timing: [When to draw]; Target: [Range or AUC/MIC]; Action if out of range: [Adjustment plan] (Include only if applicable)
• Data needed to finalize dosing: [Missing labs or clinical data required, e.g., updated SCr, INR, weight / none]
• Follow-up ownership: [Who will reassess (pharmacy / primary team)] by [Specific date/time or interval]

Communication / Order Status

• Notification: [Provider/team notified] via [secure message / phone / in-person] at [Date/Time]
• Response: [accepted / modified / declined] [Reason if modified or declined]
• Order status: [Orders placed by name / pending / not placed]
• Patient counseling: [Provided with key points / not provided] (Include for outpatient or high-risk therapies)