Date: _____________

Person Requesting Change: _____________________

Patient Care Service: ____________ Patient Care Units: _________________

Medical Director of Service Area: __________________________

Nurse Manager of Service Area: ___________________________

Medication Involved: ____________________________________

Parameter to be changed: _______________________________________________
___________________________________________________________________
___________________________________________________________________

Include the information/resource/documentation supporting the change: ___________________________________________________________________
___________________________________________________________________

Other appropriate information: ____________________________________________

Please submit this request to the Drug Library Owner in Pharmacy. A representative from Clinical Practice in Nursing and the Drug Library Owner will review the materials submitted and facilitate the approval process. The Nurse Manager and Medical Director must endorse and can assist in making this request. Approvals will be made in closed session and will be communicated either via email or verbally. A notation will be made on this form.

Signature of Requester: ______________________________      Date: __________

Signature of Medical Director: _________________________      Date: __________

Signature of Nurse Manager: __________________________      Date: __________