<p> Medication Audit Criteria and Guidelines Drug Audit Checklist</p><p>Reviewer: Date: Class: Drug: valproic acid (Depakene®), divalproex sodium (Depakote®, Depakote® ER)</p><p>Audit# Comments Requires Phys. Review Patient# Yes No Ordering Physician</p><p>S 1. Cyclic mood disorders N</p><p>O 2. Aggressive behavior secondary to a psychiatric I T</p><p>- disorder</p><p>A 3. Impulse control disorders C I 4. Acute mania D N I s s n b 1. History of anaphylactic reaction or similarly o A i t t severe significant hypersensitivity to the u a l c o i medication prescribed e d n e i</p><p> v 1. Hepatic disease/impairment i a t r a t l n e</p><p> o 2. Blood dyscrasias, clotting disorders or R C concomitant drugs that alter clotting function (aspirin, non-steroidal anti-inflammatory drugs, warfarin, heparin, low molecular weight heparins, clopidogrel etc.) 3. Pregnancy/nursing mothers s G r 1. CBC - with differential and platelet count e N t I e - baseline then one (1) to two (2) weeks after R m a O each dosage increase, and as clinically r T a I indicated P N </p><p> g 2. Hepatic function panel- baseline and as O n i M r clinically indicated</p><p> o t T i 3. Pregnancy Test – baseline and as clinically N n o E indicated I M T</p><p> t 4. Valproic acid level – 1-2 weeks after A n P e initiation and dosage change, then as i t</p><p> a clinically indicated. P 5. Serum creatinine and BUN at baseline and as clinically indicated g</p><p> n Take with food to avoid stomach upset i s o</p><p>D See DSHS/DADS Formulary for dosage guidelines.</p><p>Exceptions to maximum dosage must be justified as per medication rule.</p><p>Drug: valproic acid (Depakene®), divalproex sodium (Depakote®, Depakote® ER) Drug Audit Checklist </p><p>Drug Audit Checklist Page 1 of 2 Revised April, 2010 Patient# Comments Requires Phys. Review Yes No Ordering Physician</p><p>Date Date Comments Physician's Referred Reviewed Signature</p><p>Additional Comments:</p><p>Drug Audit Checklist Page 2 of 2 Revised April, 2010</p>