Data Reporting Form

REVISION 1/23/03

Use this form to report the plan for your patient's next medication trial and the outcome from this medication trial. This version of the form is being used in Algorithm Project II at Taunton State Hospital in Massachusetts. Please answer all questions and enter data accurately and completely.

Information Needed in all Reports:

Pretrial report on new patient Pretrial report on a patient who just completed another monitored trial
Report of the end of a treatment trial.

Providing only additional information for a previously incomplete report. If yes, you only need to answer the questions you wish to change.

Physician's first name: Last name:

Patient's Medical Record #: Treatment Unit #:

Patient age or Date of Birth: Sex: FemaleMale

Which algorithm was used:Schizophrenia DepressionAnxiety in Drug Abusers

DIAGNOSIS (DSM-IV Criteria) that is the target for this new medication. Select from menu - :

Report at the Start of a Treatment Trial:

Start date for this trial:

Where are you in the algorithm? Give the algorithm's most recent recommendation number: (Can be found in the flowchart.)

Medication being started or adjusted:

Is this one of the listed recommendations? If not, give your rationale for your choice of treatment. Your choice could be one of the proposed second-line treatments or any other according to what you think is best. For example, if the algorithm recommends another monotherapy trial at this point, and you have decided to do polypharmacy, explain below.

If you intend that the new medication will replace a current medication (perhaps after starting and reaching therapeutic levels of the new medication), what medication(s) do you plan to taper and stop?

List of Current Medications 

 
		
 
		
Report at the End of a Treatment Trial: 
 
		
Date trial completed: (The date of trial completion is defined as either the date the
		  patient was first considered ready for discharge in the opinion of the
		  attending psychiatrist and team, or the date that the response was determined
		  to be unsatisfactory and that preparations began for the next
		  intervention.) 
 
		
Outcome of trial:

		  Successful
		  treatment of the target diagnosis: patient is deemed eligible for discharge -
		  or would be ready if it were not for court-mandated or other problems
		  preventing discharge (e.g. sexual offender history) 
Only partially successful,
		  despite an adequate trial (see algorithm criteria): you intend to do something
		  else because the response was suboptimal.

		  Non
		  responder, despite an adequate trial.
Trial not completed because
		  you decided to do something else before the trial was over.

		  Trial
		  not completed due to unacceptable side effects (physician's decision)
Trial not
		  completed due to patient refusal (against physician's advice)
 
 
		
Other activity during this trial: During the course of this trial, did
		  you treat acute agitation or anxiety non-specifically with another
		  pharmacotherapy? (e.g. - something as a "prn" for voices or to help with sleep)
		  Or did you decide to discontinue any other medication, or treat any medical
		  problem, that you thought might be interfering with the clinical response to
		  the new medication?

		  No
		  
Yes
 If yes, specify medications(s) used or
		  discontinued and/or medical problem(s) treated.
 
		
If yes, what was the effect? Effect of first medication
		  added:Improved
		  No
		  change

		  Worse
Effect of second medication added:Improved
		  No
		  change

		  Worse
 
 
		
Clinical Global Impression of Improvement from this trial:
1 - Very Much Improved
2 - Much
		  Improved
3 - Minimally Improved
4 - No Change
5 - Minimally Worse
6
		  - Much Worse
7 - Very Much Worse
 
		
Details about the trial that was just completed. Also describe other
		  medications you may have started during this trial, that may have been required
		  to treat a different (comorbid) disorder.
 
		
Check any that apply: 

		  I followed my
		  original plan and discontinued the medication I planned to replace. 
I tried to discontinue
		  the medication I planned to replace, but the patient deteriorated so I had to
		  resume it.
I did not follow my original plan, and I kept both
		  the old and new medication.

		  I did
		  not plan to discontinue any of the other medications and I adhered to this
		  plan.
 I
		  did not originally plan to discontinue any of the other medications but I
		  changed my mind and took away the following:
		  _________________________________________________________
 
		
The next plan is: 
 
		
No more
		  trials needed because of good outcome 

		  Another trial planned
		  (Enter information about this trial on a new Data Reporting Form.) 
 
		

 No more
		  trials planned for a different reason: