St.

Johns University College of Pharmacy and Health Sciences

Self-Care Intervention Documentation Form
PHR 4201, 4202, 5201

**For any questions that do not apply simply indicate N/A in the area
provided**

1) Who is the product for: ___Self ___Spouse ___Child ___Other

2) Age _____ 3) Sex: Male or Female 4) Pregnant/Breastfeeding Y or

N

5) Allergies (medications, foods, food dyes):

_______________________________________________

6) Current Medical Conditions:

______________________________________________________________

7) Current Medications:
______________________________________________________________________

8) Chief Complaint:
___________________________________________________________________________

Analysis (PQRSTA):

P: What brought the condition on? What aggravates it?

Q: Can you describe the condition (ie: pain, rash, cough, etc.)?

R: Where is the location of the condition? What relieves it/What have you tried so far?

S: How severe is it? On a scale of 1 to 10?

T: When did it start? How long have you had it? How often does it occur? How long
does it last?

A: What else happens? Any other symptoms?

Outcome:
Select one of the following:

____ Self-Limiting ____ Seek Physician Consult ____ OTC

Recommendation

Appropriately counsel the patient on the proper course of action.

If a product or products are recommended, remember to discuss:

St. Johns University College of Pharmacy and Health Sciences
Self-Care Intervention Documentation Form
PHR 4201, 4202, 5201
o Discuss with patient the reason for choosing the product or
products
o Complete directions for use
o Appropriate patient counseling points
o Applicable non-pharmacologic treatments(s)
If a physician consult is recommended, remember to discuss why this
course of action is appropriate.