UTI Assessment

PHARMACIST ASSESSMENT – UNCOMPLICATED URINARY TRACT INFECTION
Patient
Name: HSN:
Address: DOB:
Telephone: ¨Pregnant à Refer to MD ¨ lactating
Medical History: ¨ Renal Dysfunction: CrCl = ______

Previous episode(s) of UTI diagnosed?
¨ Yes à Continue ¨ No à Refer
Previous episode of UTI within last 4 weeks?

¨ Yes à Refer ¨ No à Continue
Two or more episodes of UTI within last 6 months or three or more episodes within last 12 months?
¨ Yes à Refer for consideration of prophylaxis +/- continue assessment for treatment
Does the patient have an immunocompromising condition (including poorly controlled diabetes)?
¨ Yes à Refer
Does the patient have abnormal urinary tract function or structure?(indwelling catheter, neurogenic bladder, renal stones, renal
dysfunction, etc.)
¨ Yes à Refer
Is the patient male or <16 years of age? ¨ Yes à Refer ¨ No à Continue
Drug History/Drug Allergies:
Does the patient take a medication which suppresses the immune system? (See guideline)
¨ Yes à Refer
Does the patient take a medication which can cause cystitis? (Cyclophosphamide, allopurinol, danazol, or tiaprofenic acid)
¨ Yes à Consider discontinuation, alternatives and/ or refer
Prior treatment for UTI:

Medication:
Effect:
Tolerance:
Review of Symptoms
Does the patient have two or more of :
¨ Dysuria ¨ Frequency / Urgency ¨ Suprapubic discomfort AND ¨ No vaginal symptoms
¨Yes à Continue ¨ No à Refer for further investigation
Are any signs of pyelonephritis present?

¨ Fever ¨ Chills ¨ Nausea and vomiting ¨ Flank or back pain ¨ Significant malaise
¨No à Continue ¨ Yes à Refer

Are any other unusual symptoms present?
¨ Vaginal discharge or itch ¨ Dyspareunia ¨ Other significant symptoms
¨No à Continue ¨ Yes à Consider alternate diagnosis / refer

Treatment: (if pediatric patient, see guideline for treatment options)
First Line:
¨ Nitrofurantoin (Macrobid) 100mg PO BID x 5 days
Second Line:
¨ Sulfamethoxazole-trimethoprim 800mg / 160mg PO BID x 3 days (Avoid if used in the previous 3 months)
Or
¨ Trimethoprim 100mg PO BID x 3 days
Or
¨ Trimethoprim 200mg PO OD x 3 days
Or
¨ Fosfomycin 3g dissolved in ½ cup of cold water OD x 1 day (not indicated if <18 years old)
Prescription Issued for minor ailment

Rationale for prescribing:
Rx:
Quantity (enough for one course of treatment only):
Directions:
¨ May have prescription filled at pharmacy of choice ¨ PAR will be communicated to primary care provider as part of collaborative practice
pseudoDIN 00951103
Follow up scheduled in 3 days:

¨ Assess for significant improvement in all symptoms
¨ Determine if side effects are occurring (esp. severe diarrhea or rash)
¨ If worsening or not improving, refer to MD
¨ If improving, encourage continued use until the end of therapy if greater than 3 days
Prescribing pharmacist
Name: Signature
Telephone:
Pharmacy:
Fax:
Email: Date:
Primary Care Provider: Fax Number:

Pharmacist Minor Ailment Prescribing Record
To
This document is to inform you I met with your patient below who presented with a recurrent,
uncomplicated urinary tract infection. The patient has had this issue previously diagnosed. After an
assessment, a prescription was issued for
The prescription details and rationale for my decision are documented below. This is for your information to
keep your records for this patient up to date.
Patient Demographics:
Name: HSN:
Address: DOB:
Telephone: □ Pregnant □ Breastfeeding
Prescription Issued on __________________________
MEDICATION:
DIRECTIONS:
QUANTITY:
Rationale for prescription / relevant patient information:
I will follow-up with the patient on ________________ and discuss these items:
¨ Assess for significant improvement in all symptoms
¨ Determine if side effects are occurring (esp. severe diarrhea or rash)
¨ If worsening or not improving, refer to MD
¨ If improving, encourage continued use until the end of therapy if greater than 3 days
Prescribing Pharmacist:
Name: Signature:
Pharmacy: Telephone:
Email: Fax:
Primary Care Provider notified:
Name: Fax:

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PHARMACIST ASSESSMENT – UNCOMPLICATED URINARY TRACT INFECTION

Medical History: ¨ Renal Dysfunction: CrCl = ______

Previous episode of UTI within last 4 weeks?

Prior treatment for UTI:

¨Yes à Continue ¨ No à Refer for further investigation

Are any signs of pyelonephritis present?

¨No à Continue ¨ Yes à Refer

¨No à Continue ¨ Yes à Consider alternate diagnosis / refer

Prescription Issued for minor ailment

Quantity (enough for one course of treatment only):

Follow up scheduled in 3 days:

Primary Care Provider: Fax Number:

Telephone: □ Pregnant □ Breastfeeding

Prescription Issued on __________________________

Rationale for prescription / relevant patient information:

Primary Care Provider notified:

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