Pharmacist's Patient Care Report

Pharmacist Care Report

Students' Information

Students' Name

Group Number
Case Number and
Diagnoses
In or out patient
Day and Date
Section number
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Demographic and Administrative Information

Name (abbreviated) Patient ID
Address MD (consultant)
Phone # Senior
Date of Birth (dd/mm/yy) Age Room No
Gender Occupation
Height (cm) Weight (kg)
BMI = (Underweight/Normal/Overweight/Obese /Morbid obesity) IBW
Admission Date Discharge Date
General Health on a Scale of 10 (1 very bad-10 very good) Education Level
Marital Status Insurance

Patient Data Base

Case Summary(chief compliant and what happened to the patient during hospitalization)

History of Present Illness(location, characteristics, aggravating and alleviating factors, timing, severity)

Past Medical History/ Surgery

Family and Social History(diseases in first relatives, caregiver, living arrangement, daily activities)

Life Style(Diet, Exercise, Smoking, Alcohol, Caffeine)

Acute and Chronic Medical Problems

(Disease, stage/type/class, current status, duration)
1.
2.
3.
4.
5.
6.
7.
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What are the current signs and symptoms requiring attention?

Are these signs and symptoms secondary to drug therapy that the patient is currently taking?

Missing Lab test(s) if applicable

Lab test Normal range
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Dose Regimen Assessment Sheet
Limitations Degree Of Impairment
BSA
(NPO, Vomiting, Age Weight Renal (creatinine
(Chemotherapy) Hepatic
Inability to Swallow) clearance)

Recommended Regimen
Drug Used Medical (taking into consideration liver and kidney function, Actual Regimen Agreement
( Scientific Prob. age, other diseases, drug interactions and individual
( example : for patient characteristics)
name)
HTN , DM )
Str. Freq. Route Duration Time Meal Str. Freq. Route Duration Time Meal
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Drug drug interaction:
Potential interactions
Drugs Severity Effect (discussion) Patient management
Drug 1
--------------------------
Drug 2
--------------------------

…………..
Drug 1
…………..
--------------------------
Drug 2
--------------------------
……………

…………..
Drug 1
--------------------------
Drug 2
--------------------------
…………..

Treatment
………….. Related Problems Assessment Sheets

Type Of Problem Assessment Drugs Involved/Comments

a) Drug use without an indication
b) Addiction or recreational drug use
c) The patient treatment should be stepped down (at
this stage the patient needs non pharmacological
therapy alone or he doesn’t need combination
therapy because of improvement in condition or
because of guideline recommendations)
1. Unnecessary drug therapy
d) Duplication (two drugs from the same
pharmacological class with no clinical evidence
approving such combination)
e) Treating avoidable adverse reaction
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2. Untreated condition a) Untreated conditions that require pharmacological

or non-pharmacological therapy

a) More effective drug is available/ recommended

b) The patient requires additional/ combination
therapy or stepping up because of actual or potential
3. Efficacy therapy failure or because of guidelines
recommendation
c) Efficacy dosage regimen issues
d) Efficacy interactions issues

a) A current drug is contraindicated/unsafe for

patient condition and should be stopped, monitored
or replaced
b) a safer drug is recommended
c) The patient is at high risk for developing ADR and
needs monitoring or prophylaxis
4. Safety
d) Allergic reaction or an undesirable effects: Are
there symptoms or medical problems that may be
drug induced?
e) Safety dosage regimen issues
f) Safety interactions issues

a) The patient is not instructed or does not

understand important information regarding his
medications (the purpose of his or her medication(s),
how much, how and when to take it, what to avoid,
5. Inappropriate knowledge how to prevent side effect and how to monitor his
treatment)
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6. Inappropriate adherence
7.Miscellaneous
8. Treatment related problems on
discharge medications
• Assessment section: answer by yes or no
• Comments section: describe the treatment related problem and the drugs involved
b) The patient is not instructed or does not
understand non-pharmacological therapy or self-care
advice (avoidance of risk factors, smoking, alcohol,
diet, exercise, etc.)
a) A problem in patients' adherence to medications
(forget, skip, can’t afford, can’t swallow/administer
drug etc)
b) Drug product not available
c) A problem in patients' adherence to self-care
activities or non-pharmacological therapy
a) A need for additional or more frequent monitoring
b) A need for additional diagnostic test
c) A need for consultation
d) The chosen medication(s) is not (are not) cost
effective
e) Other dosage regimen issues
f) Other interaction issues
g) Patient was discharged too early (i.e. before
achieving recommended target)
h) Administering errors
i) Dispensing errors
a) Unnecessary drug therapy
b) Untreated condition
c) Ineffective/incomplete drug therapy
d) Actual and potential ADR
f) Actual and potential drug interactions
g) Inappropriate knowledge
h) Inappropriate adherence
i) Miscellaneous
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Pharmacist Care Plan*

Pharmacotherapy Goals
Recommendations
Treatment Related Physician
(Pharmacological, Non-pharmacological, Others)
Medical Problem Issue (cure a disease; reduce/eliminate signs and/or symptoms; Action
slow or arrest the progression of a disease;
or health care ( TRP OR DTP ) ** therapeutic regimen should include which drug(s) should be started
# prevent a disease or symptoms; normalize physiologic or Agreed and
need ( example : (example : indication , laboratory parameters. Specific goals of therapy include: 1) (e.g. new drug added) or changed (e.g. increase or decrease in dose),
Not agreed
HTN , DM ) effectiveness , safety stopped or continued. This should include: the drug, dose, route,
clinical parameters; 2) degree of change or progress; and
frequency, and duration of therapy.
and compliance ) 3) time frame.)

1 Pharmacological and Non-pharmacological :

2
Pharmacological and Non-pharmacological :
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Pharmacist Care Plan Monitoring Sheet/Follow up*

Monitoring Parameters (subjective, Endpoint

Goal# Freq. Comments
physical, labs, other tests) (Units)

* Use the lab data in patient data base to assess the achievement of outcomes
 ‫‪Pharmacist's Patient Care Report‬‬

‫)‪Counseling provided: (in language used with patient, point form‬‬

‫‪Date:………………………………………….‬‬
‫‪in person‬‬ ‫‪telephone‬‬ ‫‪patient‬‬ ‫‪agent‬‬

‫أي ﺗﻌﻠﯿﻤﺎت ﺧﺎﺻﺔ‬ ‫اﻟﺠﺮﻋﺔ‬ ‫اﻷدوﯾﺔ‬

‫اﻷﻣﻮر أو اﻟﻌﻮاﻣﻞ أو طﺒﯿﻌﺔ‬ ‫)ﻣﺮاﻗﺒﺔ ﻣﻀﺎﻋﻔﺎت اﻟﺪواء‪ ،‬ﻣﺮاﻗﺒﺔ‬ ‫)ﻣﺜﺎل ‪:‬ﺣﺒﺔ ﻣﺮﺗﯿﻦ ﯾﻮﻣﯿﺎ ﺑﻌﺪ اﻷﻛﻞ(‬ ‫‪Discharge Meds‬‬
‫اﻟﻄﻌﺎم اﻟﺘﻲ ﯾﺠﺐ ﺗﺠﻨﺒﮭﺎ ﺑﺎﻟﻨﺴﺒﺔ‬ ‫ﻓﺎﻋﻠﯿﺔ اﻟﺪواء‪ ،‬ﺗﺨﺰﯾﻦ اﻟﺪواء‪ ،‬ﻣﻨﻊ‬
‫ﻟﻠﻤﺮض‬ ‫ﻣﻀﺎﻋﻔﺎت اﻟﺪواء(‬ ‫اﻻﺳﻢ‬ ‫اﻻﺳﻢ‬
‫اﻟﺘﺠﺎري‬ ‫اﻟﻌﻠﻤﻲ‬