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Clinical pharmacist intervention note in patient file

Patient named:- Department:

By reviewing patient medications it is found that patient has the following

MedicationRelated problem(s):
1 □ inappropriate indication 8
□ Duplication
2
□ inappropriate dose or regimen 9
□ Discontinuation of needed medication
3
□ Compliance/ nurse management problem 10
□ Therapeutic failure
4
□ Adverse Medication reaction 11
□ Untreated medical condition
5 12
□ Medications interaction:- □Lack of necessary Medication monitoring
□Medication □Food □Lab □Habits□Herb
6
□ Contraindication 13
□ Need for additional Medication therapy
7
□ unnecessary medication 14
□ others
Recommendations:
Inappropriate Regimen
Patient Only Doing Hemodialysis 3.5 hour Twice A week The Guidelines
Recommended
hemodialysis treatment lasts about four hours and is done three times per week.

Lack Of Monitoring Patient Not routinely Monitoring test HIV or HCV ar HBV
Test Done only in admission but patients has symptoms of liver disease that ,so we
recommended procedure virus investigation due to may be indication for Hepatic Virus

Lack Of Necessary Monitoring Electrolyte , Minerals ( Ca , Phosphate ) And PTH '

VITD
So We Recommend TO Monitoring
Electrolyte After Dialysis
Ca , phosphate Every 3 M
PTH Every 3-6 M If Elevated Add Calcitriol 0.25 mcg once Daily may increase by 0.25mcg/day at 4-8
week intervals up to 0.5-1 mcg/da

Patient risk
HTN , CV and PCI or CABG
References sores
ACCP Principle and Practice Pharmacotherapy KDIGO Guidelines
Physician comments
No Physican Found

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 Supervisor signature
Dr/Yasseen AL-Sharab

Clinical pharmacist daily intervention note

Date Description Recommendations Acceptance
[2022] (Mention
reason if
rejected)
on pt on dialysis for one Inappropriate Regimen Rejected Red
Dialysis years due to HTN , CV Marker
Patient Only Doing Hemodialysis 3.5
Twice event PC and analgesic
hour Twice A week The Guidelines
Weekly medication
currently on HTN ,DM Recommended
medication , aspirin ,statin hemodialysis treatment lasts about four hours
and vitamins supplements and is done three times per week.

Lack Of Monitoring Patient Not routinely

Monitoring test HIV or HCV ar HBV
Test Done only in admission but patients
has symptoms of liver disease that ,so we
recommended procedure virus
investigation due to may be indication for
Hepatic Virus

Lack Of Necessary Monitoring

Electrolyte , Minerals ( Ca ,
Phosphate ) And PTH ' VITD
So We Recommend TO Monitoring
Electrolyte After Dialysis
Ca , phosphate Every 3 M
PTH Every 3-6 M If Elevated Add Calcitriol
0.25 mcg once Daily may increase by
0.25mcg/day at 4-8 week intervals up to
0.5-1 mcg/da

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 Name of week Interior Surgery and Emergency Respiratory
department dialysisdepartment and ICU department

One month and A+B D+C E+F

one week
One month and D+C E+F A+B
one week

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