patient assessment forms alt format 2010

7/30/2019 Patient Assessment Forms Alt Format 2010

1/12

Patient: Date: Pharmacist:

PHARMACISTS PATIENT DATABASE FORM

Patient Name: Patient ID: Location:

Address: Physician:

Pharmacy:

Date of Birth: Race: Sex:

Height: Weight:

Date of Admission/Initial Visit: Occupation:

HPI, PMH, FH, SH, etc.

Prioritized Medical Problem List Medication ProfileAllergies/ADRs

No known drug allergies/ADRs

Not known/inadequate information

Drug: Reaction:


2/12

Patient: Date: Pharmacist:


3/12

VITAL SIGNS, LABORATORY DATA, DIAGNOSTIC TEST RESULTS

Date

Wt

Temp

BP

Pulse

Resp

Na (135-145 mEq/L)

K(3.3-4.9 mEq/L)Cl (97-110 mEq/L)

CO2/HCO3 (22-30 mEq/L)

BUN (8-25 mg/dL)

Creat (M: 0.7-1.3 mg/dL, F: 0.6-1.1 mg/dL)

Creat Clear. (85-135 mL/min)

Glucose (fasting) (80-110 mg/dL)

H/H (M: 13.8-17.2/40-50, F: 12.1-15.1/36.1-44.3)

MCV (80-98)

WBC (4000-10,000)

Diff

Platelet (140-440K)

Albumin (3.5-5 gm/dL)

T bili (0.3-1.1 mg/dL)

D bili (0-0.3 mg/dL)

AST (11-47 IU/L)

ALT (7-53 IU/L)

Alk phos (38-126 IU/L)

Total Ca (8.6-10.3 mg/dL)

Mg (1.3-2.2 mEq/L)

PO4 (2.5-4.5 mg/dL)

Other labs, diagnostic info, notes


4/12

DRUG THERAPY PROBLEM WORKSHEET

Type of Problem Possible Causes Problem List Notes

Correlation between drugtherapy and medical

problems

Drugs without obvious medical indications

Medications unidentified

Untreated medical conditions

Need for additional drugtherapy

New medical condition requiring new drug therapy

Chronic disorder requiring continued drug therapy

Condition best treated with combination drug therapy

May develop new medical condition without

prophylactic or preventative therapy or premedication

Unnecessary drug therapy Medication with no valid indicationCondition caused by accidental or intentional

ingestion of toxic amount of drug or chemical

Medical problem(s) associated with use of orwithdrawal from alcohol, drug, or tobacco

Condition is better treated with nondrug therapy

Taking multiple drugs when single agent as effective

Taking drug(s) to treat an avoidable adverse reactionfrom another medication

Appropriate drug selection Current regimen not usually as effective as otherchoices

Current regimen not usually as safe as other choices

Therapy not individualized to patient

Wrong drug Medical problem for which drug is not effective

Patient has risk factors that contraindicate use of drug

Patient has infection with organisms resistant to drug

Patient refractory to current drug therapy

Taking combination product when single agentappropriate

Dosage form inappropriate

Medication errorDrug regimen PRN use not appropriate for condition

Route of administration/dosage form/mode ofadministration not appropriate for current condition

Length or course of therapy not appropriate

Drug therapy altered without adequate therapeutictrial

Dose/interval flexibility not appropriate

Dose too low Dose/frequency too low to produce desired responsein this patient

Serum drug level below desired therapeutic range

Timing of antimicrobial prophylaxis not appropriate

Medication not stored properly

Medication error


5/12

DRUG THERAPY PROBLEM WORKSHEET (CONT.)

Type of Problem Possible Causes Problem List Notes

Dose too high Dose/frequency too high for this patient

Serum drug level above the desired therapeutic range

Dose escalated too quickly

Dose/interval flexibility not appropriate for thispatient

Medication error

Therapeutic duplication Receiving multiple agents without added benefit

Drug allergy/adverse drug

events

History of allergy or ADE to current (or chemically-

related) agentsAllergy/ADE history not in medical records

Patient not using alert for severe a llergy/ADE

Symptoms or medical problems that may be drug-induced

Drug administered too rapidly

Medication error, actual or potential

Interactions (drug-drug, drug-disease, drug-nutrient, drug-

laboratory test)

Effect of drug altered due to enzymeinduction/inhibition from another drug patient is

taking

Effect of drug altered due to protein bindingalterations from another drug patient is taking

Effect of drug altered due to pharmacodynamicchange from another drug patient is taking

Bioavailability of drug altered due to interaction with

another drug or food

Effect of drug altered due to substance in food

Patients laboratory test altered due to interference

from a drug the patient is taking

Failure to receive therapy Patient did not adhere with the drug regimen

Drug not given due to medication error

Patient did not take due to high drug cost/lack of

insurance

Patient unable to take oral medication

Patient has no IV access for IV medication

Drug product not available

Financial impact The current regimen i s not the most cost -effective

Patient unable to purchase medications/no insurance

Patient knowledge of drugtherapy

Patient does not understand the purpose, directions, orpotential side effects of the drug regimen

Current regimen not consistent with the patientshealth beliefs


6/12

PHARMACEUTICAL CARE PLAN

Medical

Problem ListCurrent Drug Regimen

Drug

Therapy

Problems

Therapy

Goals, Desired

Endpoints

Therapeutic

Recommendations

Rational

e

Therapeutic

AlternativesMonitoring

Diabetes

Militus tipe 2

(8 tahun yang

lalu)

Metformin 1000 mg 2 x

sehari

Hanya dapat

menunkan 1-2

% HbA1C

sehingga

dibutuhkanterapi

tambahan obat

OAD

HbA1C > 7 Tambahkan

tiazolidinediones

(pioglitazone dengan dosis

15-30 mg 1 kali sehari &

rosuglitazone 4-8 mg 1-2xsehari)

-

CKD (3 tahun

yang lalu)

Digunakan obat yang tidak

memperparah CKD

- Mempertahanka

n fungsi renal

pasien

Memberi obat yang cocok

untuk pasien CKD

-

Hipetensi (2

tahun)

Lisinopril 10 mg 1x sehari

HCTZ 12,5 mg 1x sehari

Lisinopril

tidak cocok

untuk DM tipe

2 tetapi DM

tipe 1

sehungga

penggunaan

Lisinopril

digantikan

dengan

Ramipril.HCTZ

penggunaanny

a kurang tepat

karena ClCr

Pasien


7/12

yaitu Total

kolesterol

tinggi (45)

; Kadar Tc

tinggi (> 125)

HDL >45

Dan trigliserida


8/12

diberikan obat

batuk non

produktif

(karena

bbatuk ini

kemungkinan

disebabkan

karena efek

samping)

Kadar PPS

tinggi

- Berhubungan

dengan DM

Kadar PSS


9/12


10/12

PHARMACEUTICAL CARE PLAN (CONT.)

Medical

Problem List

Current Drug

Regimen

Drug Therapy

Problems

Therapy Goals,

Desired

Endpoints

Therapeutic

RecommendationsRationale

Therapeutic



11/12

PHARMACEUTICAL CARE PLAN (CONT.)

Medical

Problem List

Current Drug

Regimen

Drug Therapy

Problems

Therapy Goals,

Desired

Endpoints

Therapeutic

RecommendationsRationale

Therapeutic



12/12

Patient: Date: Pharmacist: Lauren Bartoli

PATIENT EDUCATION SUMMARY

patient assessment forms alt format 2010

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