ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
ANTICOAGULATION
CARDIOLOGY
FAMILY MEDICINE
INFECTIOUS DISEASES
INTERNAL MEDICINE
ONCOLOGY
PEDIATRICS
PSYCHIATRY
SURGERY
Hours of clinic per week (all clinics)
Number of patient encounters per week (all clinics,
all non-pharmacy healthcare providers)
Hours of pharmacy clinic per week (all clinics)
Number of pharmacist - patient encounters per
week
Percentage of total patient visits at facility have
encounters with pharmacist
INDICATE Y/N/NA
(YES/NO/NOT APPLICABLE)
PHARMACIST/PHARMACY PROVISION OF THE FOLLOWING
SERVICES FOR EACH CLINIC LISTED:
0
0
0
0
0
0
0
0
0
0
50
116
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
40
53
0
0
0
0
0
0
0
0
0
0
0
46%
0
0
0
Cardiology
Fam Med
ID
Int Med
Oncology
Pediatrics
Psychiatry
Surgery
ASHP Program Code: 012345
% of Residency Training Conducted at this site*: 100
AC
Name of Organization: WHATTA HOSPITAL
Location: ATLANTA, GA
DIRECTIONS: ESTIMATE ALL THAT APPLY BY
RECORDING THE INFORMATION REQUESTED IN
THE BOX THAT CORRESPONDS TO THE PATIENT
CARE SERVICES PROVIDED AT THE RESIDENCY
SITE
(ADD/DELETE/RENAME AREAS, AS NEEDED)
Medication history/profile review
Medication reconciliation
Prospective medication regimen design, initiation,
and monitoring
Conduct physical assessment appropriate for drug
therapy
Provide point-of-care testing (e.g., blood glucose,
coagulation)
Order drug therapy-related laboratory tests
Recommend/implement therapeutic changes
Write progress notes in patient’s permanent
medical record
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y
N
Y
0
0
0
0
0
0
0
0
0
0
0
0
0
0
N
0
0
0
0
0
0
0
0
N
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y
Y
Y
0
0
0
0
0
0
0
0
0


Fam Med
ID
Int Med
Oncology
Pediatrics
Psychiatry
Surgery
Clinical interventions documentation
Provide patient-specific drug information
Patient education
Consultation services: nutrition, pain, other
Drug preparation and distribution (e.g.,
chemotherapy, infusion center)
Oversee drug distribution services/automated
dispensing cabinets/samples
Wellness promotion programs (e.g., screenings)
Medication administration (e.g., immunizations)
Medication Use Evaluation participation
Participate in multidisciplinary committees
Create, implement, maintain treatment
guidelines/protocols/order sets
Pharmacy Student APPE’s Offered
If Yes, approximate # per year
Resident Learning Experience Offered
If Yes, approximate # per year
Onsite retail pharmacy service available
If Yes, approximate # prescriptions dispensed per
month:
Cardiology
INDICATE Y/N/NA
(YES/NO/NOT APPLICABLE)
PHARMACIST/PHARMACY PROVISION OF THE FOLLOWING
SERVICES FOR EACH CLINIC LISTED:
AC
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y
Y
Y
N
Y
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
N
N
Y
Y
Y
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Y
5
Y
1
N
N/A
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
If training site is a multiple-site residency program, grids must be completed for all practice sites involved in the residency program as applicable to training
Multiple-site residency definition: a residency site structure in which multiple organizations or practice sites are involved in the residency program. Examples include programs in which:
residents spend greater than 25% of the program away from the sponsoring organization/main site at another single site; or there are multiple residents in a program and they are homebased in separate sites.
http://www.ashp.org/DocLibrary/Accreditation/ASD-Accreditation-Regulations-Residencies.aspx
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
ASHP Program Code: 012345
% of Residency Training Conducted at this site*: 100%
SURGERY
CARDIAC CARE UNIT
MEDICAL/SURGICAL ICU
CARDIOVASCULR ICU
ONCOLOGY/PULMONARY
OB-GYN
NEONATAL ICU
PEDIATRICS
PICU
PSYCHIATRY
TRAUMA/
BURN
TRANSPLANT
EMERGENCY DEPARTMENT
OPERATING ROOM
PRE-OP/PACU
340 BEDS, 59% OCCUPANCY RATE
MEDICINE
Name of Organization: WHATTA HOSPITAL
Location: ATLANTA, GA
Licensed Beds (total #) and Occupancy Rate (average %):
DIRECTIONS: INDICATE ALL THAT
APPLY BY RECORDING THE
REQUESTED INFORMATION IN THE
BOX CORRESPONDING TO THE
INPATIENT CARE UNITS AT THE SITE
(ADD/DELETE/RENAME AREAS, AS
NEEDED)
Are these services provided?
If yes, insert numbers of beds per
service covered.
Centralized Operations
100
100
30
35
30
50
0
0
0
0
0
0
0
50
20
20
 Hours/Days per week
(e.g., 24/7 for 24 hours 7 days per
week)
 Medication order entry (Y/N)
Dispensing Pharmacy Satellites
24/7
24/7
24/7
24/7
24/7
24/7
24/7 24/7 24/7 24/7 24/7 24/7
24/7 24/7
24/7 24/7
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N
N
 Number of beds covered
 Hours/Days per week
 Medication order entry (Y/N)
Unit-Based Pharmacists
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
20
16
10/5 10/5
N
Y
 Hours/Days per week
 Average patient load
 Medication order entry (Y/N)
Clinical Pharmacy Specialists
16/5
40
Y
16/5
40
Y
0
0
0
0
0
0
0
0
0
8/5
40
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
0
0
0
0
0
0
0
0
0
0
N/A
0
N/A
8/5
20
8/5
30
4/5
15
2/5
2
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
8/5
50
0
N/A
0
N/A


Hours/Days per week
Average patient load
Y
80%
N/A
80%
N/A
80%
N/A
80%
N/A
80%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
80%
N/A
80%
N/A
80%
N/A
Extemporaneous compounding
services
Automated Dispensing Cabinetry
System Name:____PYXIS__________
ESTIMATE % OF USE CORRESPONDING TO
99%
99%
99%
99%
99%
99%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
99%
99%
99%
PATIENT CARE AREAS
Controlled Substances
PRN medications
Emergency medications
Scheduled doses
Interfaced with pharmacy’s clinical
information system (Y/N)
AUTOMATION/TECHNOLOGY
ESTIMATE % OF USE IN PATIENT CARE AREAS
Computer Provider Order Entry
(CPOE)
System Name:
Electronic Medication Administration
Record
System Name: CAREFUSION
Electronic Health Record:
Preop/
PACU
80%
N/A
OR
99%
99%
ED
99%
95%
Transplant
99%
99%
Trauma/
Burn
N/A
N/A
Psychiatry
N/A
N/A
PICU
N/A
N/A
Peds
N/A
N/A
NICU
N/A
N/A
OB-GYN
N/A
N/A
Oncology
99% N/A
100% N/A
CVICU
99%
99%
MSICU
99%
99%
CCU
99% 99% 99%
100% 100% 99%
Surgery
Unit-dose oral drug products
Sterile product admixture service:
IVPB, LVP, chemotherapy, TPN
Unit-dose parenterals: IV push, IM, SC
24-hour cart fill
(Manual Pick___ vs Robot ___)
FOLLOWING SERVICES
Medicine
Preop/
PACU
N/A
OR
N/A
ED
N/A
Transplant
N/A
Trauma/
Burn
N/A
Psychiatry
N/A
PICU
N/A
Peds
Y
NICU
N
OB-GYN
N
Oncology
N
CVICU
N/A
MSICU
PHARMACY SERVICES – DISTRIBUTION
ESTIMATE % OF PATIENTS COVERED BY THE
N/A
CCU
Medication order entry (Y/N)
Surgery

Medicine
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
100%
100%
100%
100%
N
10%
10%
10%
N/A
N
100%
100%
100%
100%
Y
0%
0%
0%
0%
0%
0%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
0%
0%
0%
100% 100% 100% 100% 100% 100% N/A
N/A
N/A
N/A
N/A
N/A
N/A
0%
0%
0%
30%
N/A
N/A
N/A
N/A
N/A
N/A
0%
10%
0%
30%
50%
50%
50%
30%
N/A
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
N
N
Y
N
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Preop/
PACU
N
N
Y
N
OR
N
N
Y
N
ED
N
N
Y
N
Transplant
N
N
Y
N
Trauma/
Burn
N
N
Y
N
Psychiatry
0%
PICU
0%
Peds
0%
NICU
N/A
OB-GYN
N/A
Oncology
N/A
VCICU
N/A
MSICU
N/A
CCU
Medication history/profile review
New medication order review
Medication reconciliation
Prospective medication regimen
design and treatment plan initiation
Pharmacokinetic monitoring services
List: Primarily Aminoglycosides &
Vancomycin,
Target drug/disease monitoring,
including recommending and/or
ordering laboratory tests/dosage
adjustment/therapeutic changes
List: IV/PO, ANTICOAGULATION
Consultation services: nutrition, pain,
etc.
List: ENTERAL/PARENTERAL
NUTRITION
N/A
Surgery
FOLLOWING PHARMACY SERVICES
100% 100% 100% 100% 100% 100% N/A
Medicine
System Name:
IDX/CAREFUSION/VISICU
Bar-code medication administration
OTHER TECHNOLOGY (Y/N)
Robot:
IV Robot:
Packager:
Carousel:
OUTSOURCED PRODUCTS (Y/N)
Type: SOME EXTEMPORANEOUS
COMPOUNDS
PHARMACY SERVICES – CLINICAL
ESTIMATE % OF PATIENTS THAT RECEIVE THE
100%
100%
5%
15%
100%
100%
5%
15%
100%
100%
5%
90%
100%
100%
5%
90%
100%
100%
5%
90%
100%
100%
5%
15%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
20%
10%
20%
10%
0%
0%
0%
0%
0%
50%
0%
0%
10%
10%
10%
10%
10%
10%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
1%
0%
0%
20%
20%
20%
20%
20%
20%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
0%
0%
0%
15%
15%
15%
15%
15%
15%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
1%
0%
0%
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
INDICATE PHARMACIST PROVISION OF THE
Medicine
Surgery
CCU
MSICU
CVICU
Oncology
OB-GYN
NICU
Peds
PICU
Psychiatry
Trauma/
Burn
Transplant
ED
OR
Preop/
PACU
FOLLOWING SERVICES FOR PATIENT CARE
AREAS LISTED (Y/N):
Participate in multidisciplinary rounds
Participate in multidisciplinary
committees
Participate in/contribute to clinical
outcomes measures
Provide patient-specific drug
information
Provide patient education and
discharge counseling
N
Y
N
Y
Y
Y
Y
Y
Y
Y
N
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N
N
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N
N
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N
N
Participate in interdisciplinary
education
Participate in medication use
evaluation studies
Create, implement, maintain
treatment guidelines/protocols/order
sets
Document recommendations in
patient’s permanent medical record
Document clinical interventions
System name if used: QUANTIFI
Document adverse drug reactions
System name if used: MIDAS
Manage investigational drug
products/studies
Reconcile non-electronic medication
administration records
Participate in medical emergencies
Others, List:
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Pharmacy Student APPE’s Offered
If Yes, approximate # per year
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
Y
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
Y
Y
Y
10
N
N
N
N
N
N
N
N
N
N
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N
N
N
N
N
N
ASHP ACCREDITATION SERVICES PRE-SURVEY INFORMATION: AMBULATORY CARE PHARMACY SERVICES
Resident Learning Experiences
Offered
If Yes, approximate # per year

Y
N
Y
Y
N
Y
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Y
N
N
2
N/A
2
2
N/A
2
N/A
N/A
N/A
N/A
N/A
N/A
N/A
2
N/A
N/A
*If training site is a multiple-site residency program, grids must be completed for all practice sites involved in the residency program as
applicable to training
 Multiple-site residency definition: a residency site structure in which multiple organizations or practice sites are involved in the
residency program. Examples include programs in which: residents spend greater than 25% of the program away from the sponsoring
organization/main site at another single site; or there are multiple residents in a program and they are home-based in separate sites.
http://www.ashp.org/DocLibrary/Accreditation/ASD-Accreditation-Regulations-Residencies.aspx