"Antipsychotic Monitoring Chart"

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PATIENT 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: http://www.wch.sa.gov.au/antipsychotic
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
PATIENT 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: http://www.wch.sa.gov.au/antipsychotic
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
3. Blood tests recommended for all antipsychotics (baseline, at 3 months, then yearly)
Bloods should be taken in the morning in a fasting state and before giving medication
New Antipsychotic
Ongoing
Ongoing Use
Starting
Investigations
Baseline
Month 3
Month 12
Point
Date of blood taken
Total Cholesterol *
Triglycerides *
Blood Glucose
White Blood Cell (WBC) Count †
Neutrophil Count †
Liver Function Tests (Normal Y/N) #
Urea & Electrolytes (Normal Y/N) #
Prolactin **
Name, Signature &
Designation
4.1 Questions to ask for all antipsychotics to monitor for extrapyramidal side effects **
(baseline, monthly for 3 months, then every 3 months)
New Antipsychotic
Ongoing
Ongoing Use
Starting
Observations
Baseline
Month
Month
Month
Month
Month
Month
Point
(please indicate with a tick = yes, x = no)
1
2
3
6
9
12
Any muscular tremors or spasms
ie dystonia?
Any muscular stiffness or rigidity
ie Parkinsonism?
Any restlessness or agitation
ie akathisia?
Any involuntary hyperkinetic movements
ie dyskinesia?
4.2 Questions to ask or consider for all antipsychotics to monitor for hyperprolactinaemia **
(baseline, monthly for 3 months, then every 3 months)
Ongoing
New Antipsychotic
Ongoing Use
Starting
Observations
Baseline
Month
Month
Month
Month
Month
Month
Point
(please indicate with a tick = yes, x = no)
1
2
3
6
9
12
Any milk leakage from your breasts?
Any breast enlargement?
Have menstrual periods ceased or
become irregular?
Any loss of sexual function or desire?
Stunted growth or delayed puberty?
Name, Signature &
Designation
5. Interventions required
Baseline
Month 1
Month 2
Ongoing
Month 3
Month 6
Month 9
Month 12
Starting Point
None
None
None
None
None
None
None
None
Intervention
required if
abnormality
detected
Name,
Signature &
Designation
mg = milligram
LEGEND:
* if any abnormalities are detected, a complete lipid profile is recommended
Legend:
*
if any abnormalities are detected, a complete lipid profile is recommended
kg = kilogram
† optional for patients prescribed clozapine because mandatory blood monitoring involving weekly testing for the first 18
optional for patients prescribed clozapine because mandatory blood monitoring involving
m = metres
weeks then monthly thereafter is recorded elsewhere
weekly testing for the first 18 weeks then monthly thereafter is recorded elsewhere
#
BMI = Body Mass Index
# if No, indicate abnormality
if No, indicate abnormality
Y = Yes
pay particular attention with risperidone, amisulpride, olanzapine and first generation antipsychotics
**
N = No
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