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

Tekanan darah (mmHg)
Nadi
Suhu (oC)
RR
 MEDICATION
No Nama Obat Indikasi Dosis yang Dosis Terapi
digunakan (literatur)
1
2
3

Further
No Information Alasan Jawaban
Required
1.
2.
3.
4.
5.

Problem List (Actual Problem)

Medical Pharmaceutical
 PHARMACEUTICAL PROBLEM

Subjective (symptom)

Objective (signs)

Assesment (with evidence)

Plan (including primary care implications)

Monitoring
a) Evektivitas

b) Efek Samping Obat