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Description

Describes the patient’s response to the adverse event

On-Screen Instructions

Select all that apply.

Field Type

Checkbox (multiselect)

Responses

  • Satisfied with resolution

  • Concerned or anxious

  • Upset or angry

  • Threatened legal action or Board of Pharmacy report

  • Unknown

  • Other (please describe)

Guide for Use

If “Other” is selected, a text box for a description will also appear.

This question applies to the patient’s reaction at the time of PSRP report submission, regardless of their initial reaction.

History

Start Date

Summer 2013

End Date

n/a

Change History

n/a

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