KMCH COLLEGE OF PHARMACY

DEPARTMENT OF PHARMACY PRACTICE

PHARMACEUTICAL CARE PATIENT RECORD

Patient name Patient ID Age

DEMOGRAPHICS

Gender Room no Bed no

Height Weight BMI

Date of admission Date of Discharge Date of

Documentation

Chief Complaint

Present Medical Illness

Past Medical History

Surgical History

Family History
Social History

Smoker: Y /N Alcohol: Y / N Tobacco chewing: Y /N Routine Exercise :Y / N

Recreation: Y /N Veg / Non-Veg Salt Intake low /High Martial Status: Y / N

Occupation: Other:

Vaccination History(If any)

Indication
(Confirm with Drug Name Dosage START STOP Clinical
Patient) Regimen DATE DATE Outcomes
PAST PRESCRIPTION AND NON PRESCRIPTION MEDICATIONS HISTORY
 Medication Allergies (Drug, timing, Reaction such as Rash, Shock, asthma, nausea, anemia)
ALLERGIES

Adverse Reactions to drugs in the past

General Weight loss Throat Bleeding gums

Systems weight gain dry mouth
fatigue sore throat
weakness hoarseness
appetite Dentures
fever sore tongue
chills Non-healing sores
night sweats Thrush
Skin Rashes last dental exam
pruritus Breasts lumps
bruising pain
dryness Nipple discharge
Head Trauma Gynecomastia
headache self-examination
tenderness Respiratory wheezing
dizziness dyspnea
syncope cough
Eyes Vision hemoptysis
REVIEW OF SYSTEMS

photophobia shortness of breath

blurring Cardiovascular Chest pain
diplopia orthopnea
spots or floaters dyspnea on exertion
inflammation paroxysmal nocturnal
dyspnea
discharge murmurs
dry eyes Pain while walking
excessive tearing peripheral edema
cataracts palpitations
glaucoma Gastrointestinal Dysphagia
Last eye exam heartburn
Glasses or contact nausea
Ears Hearing changes vomiting
tinnitus hematemesis
pain indigestion
discharge abdominal pain
vertigo diarrhea
history of ear infections constipation
Nose Sinus problems hematochezia
epistaxis hemorrhoids
Itching melena
Stuffiness jaundice
Discharge fatty food intolerance
Sinus problems odynophagia
epistaxis excessive belching
 Genitourinary Frequency Neurologic Fanting
Urgency Blackouts
Hesitancy Seizures
Dysuria Paralysis
Hematuria Local Weakness
Nocturia Numbness
Incontinence Tingling
Venereal Disease Tremors
Discharge Memory Changes
Sterility Haeadaches
REVIEW OF SYSTEMS CONT...

Impotence Vertigo Or Dizziness

Polyuria Muscle Atrophy
Change Peripheral Vascular Varicose Veins
In Urinary Stream
Endocrine Polydipsia Intermittent Claudication
Polyphagia Thrombophlebitis
Temperature Intoler- Hematology Anemia
ance
Glycosuria Bleeding Tendency
Hormone Therapy Easy Bruising
Changes In Hair Or Lymphadenopathy
Skin Texture
Musculo Arthralgias, Psychiatric Anxiety
skeletal Arthritis Insomnia
Trauma Depression
Joint Swelling/Pain Irritability
Redness Nervousness
Tenderness Nightmares
Gout Phobias
Back Pain Tension
Tendonitis Confusion

GENERAL APPEARANCE SKIN

PHYSICAL EXAMINATION

HEAD, EYES, EARS, NOSE, AND THROAT CHEST

 CARDIAC ABDOMINAL
PHYSICAL EXAMINATION

GENITALIA/RECTAL MUSCULOSKELETAL

EXTREMITIES NEUROLOGIC

DATE TIME Temp(0C) PR(/min) RR(BPM) BP(mmHg) FLUID I/O

VITAL SIGNS MOINTORING
VITAL SIGNS MONITORING
 LAB NORMAL RANGE Date
INVESTIGATION
Full Blood Count
Hemoglobin Male 13–17.5 g/dL
Female 12–15 g/dL
TWBC 4000-11300cells/cu.mm
DC L:20-40%
P:45-75%
M:2-10%
E:2-6%
B:0-1%
RBC 4–6.2 × 106/ μ L
PCV 40-52%
MCV 80-96µm3
MCH 27-34pg/cell
MCHC 31-36g/dl
RDW 11.5-14.5%
Platelet 150000-450000cells/uL
Renal Profile
Urea 10-50mg/dL
SCr 0.7-1.2
CrCL 105-150ml/min
LABORATORY INVESTIGATIONS

Serum Electrolytes
Na 133-145mEq/L
K 3.3-5.1 mEq/L
Cl 98-106 mEq/L
Ca 2.15-2.55 mEq/L
Mg 0.66-1.07 mEq/L
PO4- 0.74-1.52mmol/L
Liver Function Profile
Albumin 3.4-5.2g/dL
Globulin 1.5-3.5 g/dL
Bilirubin T:0-1mg/dL
D:0-0.25 mg/dL
In:0-0.75mg/dL
ALT(SGPT) 0-31u/L
ALP 0-104u/L
AST(SGOT) 0-31u/L
Coagulation Profile Test
PT 11–16 sec
aPTT 25.4–38.4 s
INR <1.5
Cardiac Enzyme
CK M: 24–195 IU/L
F:20–170 IU/L
LDH 140 U/L– 280 U/L
Troponin I Less than 1.5 ng/mL
Troponin T Less than 0.1ng/mL
AAT <37
Arterial Blood Gases
PH 7.35-7.45
PCO2 35-45mmHg
PO2 80-90mmHg
 HCO3 22-29mmol/L
O2saturation 90-95%
LABORATORY INVESTIGATIONS

Lipid Profile
T. Cholesterol 0-200mg/dL
C-TG 40-200mg/dL
C-HDL >40mg/dL
C-LDL <3.9mmol/L
Blood Glucose Test
FBS 60-100mg/dL
RBS 75-125mg/dL
HbA1C 4-6%
Other

DATE
Specific Gravity
Color
Clarity
PH
Albumin
URINALYSIS

Glucose
ketones
Bile salts
Bile Pigments
Urobilinogen
Pus cells
Bacteria
Crystals
Flagellates
Others
(If any Specify)

DATE SPECIMEN RESULT SUSCEPTIBILITIES

CULTURE RESULTS
OTHER INVESTIGATIONS(IF ANY SPECIFY) CULTURE RESULTS

CTX,ECG,CT/MRI-Scan ,ECHO,USG etc….

Creatinine Clearance Calculation For Renal failure Patient ONLY

(140-age) ×Weight(kg)
FORMULA

CL cr (ml/min)= ×(0.85 if female)

72×Serum Creatinine (mg/dl)
(or)
eGFR (Ml min/1.73m2= 175×(Scr)-1.154×(age)-0.203×(0.742 if female)
C ALCULATION

MEDICAL DIAGNOSIS

DATE PROGRESS INVESTIGATION PLAN

CLINICAL PROGRESS
 DATE PROGRESS INVESTIGATION PLAN
CLINICAL PROGRESS
 INDICATION DOSAGE REGIMEN DATE OF TREATMENT
(Confirm with DRUG NAME (DOSE, ROUTE, FREQUENCY,
Patient) DURATION)
CURRENT PRESCRIBED MEDICATIONS
 TYPE OF DRUG PRIORITY Therapeutic RECOMMENDATIONS FOR THERA- MONITORING PARAMETERS AND
RELATED PROBLEM GOALS PY ENDPOINTS
PHARMACEUTICAL CARE

SCHEDULE FOR NEXT FOLLOW-UP EVALUATION...............................................................

 TYPE OF DRUG PRIORITY Therapeutic RECOMMENDATIONS FOR THERA- MONITORING PARAMETERS AND
RELATED PROBLEM GOALS PY ENDPOINTS
PHARMACEUTICAL CARE

SCHEDULE FOR NEXT FOLLOW-UP EVALUATION...............................................................

 Status of DTPs Description
EVALUATION

DISCHARGED MEDICATION

SUMMARY OF THE OUTCOME FOR THE PATIENT

 PATIENT COUNSELLING
Name
Meds

MEDICATION BASED MEDICAL BASED DIET BASED