UNIVERSITY OF SANTO TOMAS

FACULTY OF PHARMACY

HOSPITAL PHARMACY LABORATORY

Name:_________________________________ 3 Ph Date Submitted:

Quiz
(Hospital Documentation- PMP & PDAR)

Objectives:
1. Analyze the case presented by determining the medication orders and relating it to
other patient factors (i.e. laboratory, radiology, etc.)
2. Apply the concepts on hospital documentation by completely and appropriately filling-in
the forms (PMP & PDAR).

Procedures:
1. A case scenario will be given.
2. Provide the BEST answer to the following questions.

Case Scenario #1:

A 15-year old Filipino male pediatric patient who was born on June 15, 1993, MT, was brought to the
emergency room last July 8, 2008 at around 9:45 in the morning due to injured heal. He was registered
as patient number 3256745. Five hours prior to hospitalization, MT was seen playing basketball in a
covered court at Sta. Mesa, Manila where he resides. While playing and performing a basketball trick, he
stepped on a wet floor causing him to slip and landing with his right foot twisted. The patient complaint
of intense pain with a VAS of 9/10 rating, 10 being the highest. He was given with Celecoxib 200mg
tablet upon arrival, around ten in the morning to relieve him from the pain. Chief resident-on-duty, Dr.
Reyes, assessed patient MT and noted that the following are normal: SHEENT (skin, head, eyes, ears,
nose and throat), neck, respiratory, cardiovascular, gastro/abdomen, genitourinary and neurological.
Radiological and Laboratory requests were ordered and based on the complete blood count (CBC) result
there is an increased number of white blood cell (12.02) which is beyond the normal range indicating
that there is an infection. The admitting diagnosis is Anterior Cruciate Ligament ACL of the right foot. MT
was given an intravenous line containing 0.9% Sodium Chloride 500ml to run for eight hours and was
also prescribed with Cefazolin 500mg intravenous every eight hours to be completed for seven days.
Upon condutcting interview with the patient’s mother, it was known that he has no history of previous
surgical procedures and no known allergies. On the fourth day of his admission (July 11, 2008), MT
complaint of not being able to defecate and was prescribed with Lactulose 15ml once daily at bedtime if
still no bowel movement for two days. On July 15, 2008, 8:05 in the morning, MT vomitted and
complaint of dizziness. The Doctor-in-charge prescribed him with Metoclopramide 10mg intravenous
every twelve hours for episodes of nausea and vomiting. After being seen by the pediatric team of the
hospital last July 17, 2008, he was prescribed with Ascorbic acid 500mg tablet once daily, Ferrous sulfate
325mg tablet once daily, Calicum + Vitamin D 1 tablet twice daily, Celecoxib 200mg tablet twice daily for
pain and Mupirocin ointment 2% for his abrasions on his right foot to be applied three times daily for
seven days.
Below is the treatment record utilized by the nurses-on-duty to record the time of medication
administration.
 UNIVERSITY OF SANTO TOMAS
FACULTY OF PHARMACY

1. Given the scenario, fill-in the Patient Medication Profile. Please write N/A for unfilled

details. PATIENT MEDICATION PROFILE

Patient’s Name: Ward: Hospital Date Admitted:
Social Status: Number: Date Discharged:
Date of Birth: Age: Wt: Ht: Gender:
Diagnosis:
Allergies: Diet: Attending Physician:

DATE OF
DATE/TIME STANDING MEDICATIONS
REMARKS
ORDER
SD ED NAME OF MEDICATION STRENGTH ROUTE FREQ INDICATION

AS NEEDED (PRN) MEDICATIONS

IV FLUIDS STAT MEDICATIONS

DATE OF DESCRIPTION INFUSION REMARKS DATE OF NAME OF MEDICATION STRENGTH ROUTE
ORDER RATE ORDER

TREATMENT
DATE OF DATE/TIME
ORDER SD ED NAME OF MEDICATION STRENGTH ROUTE FREQ INDICATION REMARKS
 UNIVERSITY OF SANTO TOMAS
FACULTY OF PHARMACY
Case Scenario
#2: Patient MT was scheduled on July 22, 2008 at ten in the morning for
Fecal Occult Blood Test (FOBT) and as a protocol the following
medications should be put on hold prior to the procedure: Ascorbic acid
and Ferrous sulfate. Dr. Reyes (DIC) also ordered to hold these
medications last July 19, 2008 but upon checking of CP Lilia Suarez
(Clinical Pharmacist) last July 20, 2008 at 8:30 in the morning, she found
out that Ascorbic acid and Ferrous sulfate were still administered to the
patient.

2. Given the scenario, fill-in the Clinical Pharmacist’s Intervention

Form. Please write N/A for unfilled details.

CLINICAL PHARMACIS’TS
INTERVENTION FORM
(PDAR)
Patient’s Name: Ward: Hospital Number: Date:
Social Status: Time:
Date of Birth: Age: Wt: Ht: Gender:
Diagnosis:
Allergies: Diet: Attending Physician:
Problem/s Identified:

Medication/s:

Assessment (Clinical Pharmacist):

Reference/s:

Clinical Pharmacist’s Printed Name & Signature / Date

Response: I accept

I do not accept

Printed Name & Signature / Date