EXERCISE NO.

Patient’s Medical Chart

The patient’s Medical Chart contains all significant clinical information which enables the
physicians to give effective continuing care to the patient. The chart is accurately documented; it is readily
accessible and can be easily used for retrieving and compiling information. All in-patients must have a
patient’s medical chart each as required by law.

The purposes of the medical chart are:

1. To serve as a basis for planning and continuous care of the patient;
2. To provide a means of communication between the physician and any of the
professionals contributing to the care of the patient;
3. To furnish documentary evidence for the course of the patient’s illness and treatment
during each stay in the hospital;
4. To serve as a basis for review, study, and evaluation of the care rendered to the
patient;
5. To assist in protecting the legal interest of the patient, hospital, and responsible
practitioner; and
6. To provide data for use in research and education.

A complete medical chart contains the following information:

1. Identification and sociological data
2. Personal family history
3. History of present illness
4. Physical examination
5. Special examinations such as consultation, clinical laboratory data, x-ray and other
examinations
6. Provisional or working diagnosis
7. Medical or surgical treatment
8. Gross and microscopic pathologic findings
9. Progress note
10. Final diagnosis
11. Condition on discharge
12. Follow up
13. Autopsy findings

1
Procedure:

1. Study each of the forms.

2. Identify the information derived from each form and the person responsible in accomplishing each
form.
3. Give the importance of each form.
4. Give the meaning of clinical abbreviations commonly used in a patient’s medical chart.

Information Person
Forms obtained accomplishing Importance
the form
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

2
Clinical Clinical
Abbreviation Meaning Abbreviation Meaning

ASCVD MI
ASHD NPO
BE PC
BP PCN
BRP PE
BS PH
BT PI
BUN PMH
CA QNS
CBC RBC
CC RHD
CHF SC
CNS SGOT
CPK SGPT
CSF SOB
DOA TRP
DX URI
EKG UTI
EENT WBC
FBS WNL
FUO GFR
HPI HX
IM IPPB
IV STAT

3
Questions:

1. How do doctors communicate with one another when treating the same patient of different
ailments in order to avoid interactions or untoward effects of drugs?
Answer:

2. Why is it necessary for a clinical pharmacist to be familiar with the contents of the patient’s
medical chart?
Answer:

3. In what way can a clinical pharmacist help the in-patient and his doctor?
Answer:

4. Give the importance of knowing the different clinical abbreviations and medical terms found
in the patient’s medical chart.
Answer:

5. What is the advantage of preparing the drug in unit dose?

Answer: