http://pie.med.utoronto.ca/VIC/VIC_content/VIC_pharmacyCases.

html
Pls refer to case: Nephrology 1
Assignment Activity #1: Introduction to Medical Chart

Name:

Intended Learning Outcomes:

● Students will become familiar with medical charts components to understand how they
are used in providing a drug therapy plan (DTP)
Note: Open the file nephrology and explore all the windows. Extract the info that you need ex.
For Diet orders-> admission orders : these are part of admission orders which are given upon
admission at the ER. For lab results, take only those with findings,do not include anymore those
with normal values .
Operative notes only if the px have gone to OR
Direction:
Study the medical chart components and determine the use of each in developing a DTP.

Components Type (Core or elective component) Significance in DTP

(Assessment)

Admission notes

Medical History

Laboratory Results

Pathology Reports

Physician Order
Sheets

Progress Notes

Operative Notes

Medication
Administration
Record

Vital Signs Record

Short DISCUSSION QUESTIONS
1. How does a medical chart help the pharmacist in developing a drug therapy plan?

2. How might incomplete information on a medical chart cause an inaccurate drug

treatment?