1.

FORM SOAP
PHARMACEUTICAL CARE

PATIENT PROFILE

Tn. / Ny.

Jenis Kelamin : Tgl. MRS :

Usia : Tgl. KRS :
Tinggi badan :
Berat badan :

Presenting Complaint

Diagnosa kerja :
Diagnosa banding :

 Relevant Past Medical History:

Drug Allergies:

Tanda-tanda Vital tgl tgl tgl tgl tgl tgl

Tekanan darah (mmHg)
Heart rate (x/min)
Suhu (0C)
RR (x/min)
 Medication
No. Nama Obat Indikasi Dosis yang Dosis Terapi
digunakan (literatur)
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2
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9
10
11
12
13
14
15
16

LABORATORY TEST
Test (normal range) tgl tgl
WBC (4000-10000/mm3)
Hb (L: 13-17 g/dL)
RBC (4-6x106/mm3)
Hct (L:40-54%)
PLT (150000-450000/mm3)
Gula darah puasa (76-110 mg/dL)
Gula darah 2 jam PP (90-130 mg/dL)
Cholesterol (150-250 mg/dL)
TG (50-200 mg/dl)
Uric acid (L:3,4-7 mg/dL)
Albumin (3,5-5,0 g/dL)
SGOT (0-35 u/L)
SGPT (0-37 u/L)
BUN (10-24 mg/dL)
Kreatinin (0,5-1,5 mg/dl)
Natrium (135-15 mEq/L)
Kalium (3,5-5,0 mEq/L)
No Further Information Required Alasan
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2
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7

Problem List (Actual Problem)

Medical Pharmaceutical
1 1
2 2
3 3
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5 5

PHARMACEUTICAL PROBLEM

Subjective (symptom)
- Objective (signs)
Assesment (with evidence) dan Plan (including primary care implications)

No. Keluhan/Diagnosa Terapi Temuan DRP

1
2
3
4
5
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7
8
9
10
11
12
13
14
15
16
17

Plan
 Monitoring
 Efektivitas

 Efek Samping Obat

DAFTAR PUSTAKA