Antipsychotic Monitoring Chart
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1
2PATIENT LABEL
Women’s & Children’s Hospital
Women’s & Children’s Hospital
Child & Adolescent Mental Health Service
UR Number: ...............................................................................
(please tick check box for appropriate site)
Surname: .....................................................................................
Given Names:..............................................................................
ANTIPSYCHOTIC MONITORING CHART
D.O.B.: ................................................. Sex: ................................
User Guide
A new chart should be started when:
Initiating Antipsychotic - start in “New Antipsychotic” sections, fill in “Baseline” and follow with recommended
monitoring to the right (but omit “Ongoing Starting Point”)
Switching Antipsychotics - start in “New Antipsychotic” sections, fill in “Baseline” and follow with recommended
monitoring to the right (but omit “Ongoing Starting Point”)
Ongoing (starting to monitor but not initiating) - start in “Ongoing Use” sections, fill in “Ongoing Starting Point”
(because a real baseline can’t be obtained) and then follow with recommended monitoring to the right
Ongoing (previous chart is full) – start in “Ongoing Use” sections, omit “Ongoing Starting Point” (because baseline on
a previous chart) and follow with recommended monitoring to the right
NOTE: A detailed User Guide is available at:
Chart data (fill out when starting each new chart)
Antipsychotic Name: ________________________________________________________________
o
Chart N
for Patient: _____________________
Date Chart Started: ____ / ____ / ____
Antipsychotic Use Status: [please tick one]
1. Initiating
2. Switching
3. Ongoing
1. Risk factors (check at baseline & annually) [tick if applicable]
smoking
personal/family history of diabetes
low level of activity
personal/family history of heart disease
poor diet
overweight or obese
ethnicity (please specify) ……………………………..(eg Indigenous Australian, Pacific Islander, Asian, African)
other medications (please specify) ……………………………………………………………………………………..
Name: ________________
Signature: _______________
Designation: ____________
Date: ___ /___ /___
2. Measures recommended for all antipsychotics (baseline, monthly for 3 months, then every 3 months)
New Antipsychotic
Ongoing
Ongoing Use
Starting
Investigations
Baseline
Month 1
Month 2
Month 3
Month 6
Month 9
Month12
Point
Date of measurement
Daily Dosage (mg)
Weight (kg)
Height (m)
Blood Pressure (sitting)
Name, Signature &
Designation
Calculations
Baseline
Month 1
Month 2
Month 3
Month 6
Month 9
Month12
2
Body Mass Index (BMI) (kg/m
)
BMI-For-Age Percentile
BMI Z Score (
)
if BMI>97th percentile
Name, Signature &
Designation
Please File Original in Medical Record
Continued over page
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