PATIENT DATABASE Demographic and Administration Information Patient ID : MD : Pharmacy : Weight: Race : Religion : Occupation :

Name : Address : Age : Height : Admission Date : Discharge :

Room No. : Gender :

History of Present Illness: Date RR HR emp !P H" #e$o rom" P%& GDA PH p%O'

Vital Sign/ a!oratory Data " Initial/#ollo$ %p

Past Medical History()urgery :

-amily and )ocial History : pO' H%O* !+ , Na %l

#i.estyle:

+o !aso !atang )eg #im. Mono !l.Dir Indir )GO )GP !/N )%r )esa$ !atu$

Data Ser%m &oncentration

Acute and %hronic Medical Pro"lems :

&%rrent Dr%g Therapy Drug Name(Dose()trength(Route Prescri!ed Sched%le D%ration Start " Stop Dates &ompliance/Dosing Iss%e

'edication PTA

Time ine: %ircle actual administration times and record appropriate medications and meals "elo0. 1 2 3 4 56 55 5' 5 ' * 7 8 1 2 3 4 56 55 5' 5 ' * 7 8

Allergies/Intolerances: Allergen Reaction

Social Dr%g (se Alcohol : %a..ein : o"acco :

&ost 'eds/month Insurance : 9es No %opay : Medicaid : Annual income:

Notes:

Patient : #ocation(Room : Pharmacist : Date :

D)(* THE)AP+ ASSESS'ENT ,-).SHEET /DTA,0

ype o. pro"lem Assessment Are there drug 0ithout a medical indication ; Are any medication unidenti.ied <are any unla"eled or are any:prior to admission clinic =isit:un$no0n> ; Are there untreated medical conditions ; Do they re?uire drug therapy ; 5. Presence o. Drug:Related Pro"lem A pro"lem e@ists. %omments(Notes

'. More in.ormation is needed .or a determination. %orrelation "et0een Drug herapy and Medical Pro"lem *. No pro"lem e@ists or an not needed. inter=ention is

What is the comparati=e e..icacy o. the chosen medication<s> ; Appropriate Drug )election What is the relati=e sa.ety o. the chosen medication<s> ; Has the therapy "een toilered to this indi=idual patient ;

5.

A pro"lem e@ists.

'. More in.ormation is needed .or a determination. *. No pro"lem e@ists or an inter=ention is not needed.

Drug regimen Are the prescri"ed dose and dosing .re?uency appropriate:0ithin the usual therapeutic range and(or modi.ied .or patient .actors ; Is the route(dosage .orm(mode o. administration appropriateA considering e..icacyA sa.etyA con=enienceA patient limitationA and cost ; Are doses scheduled to ma@imiBe therapeutic e..ect and compliance and to minimiBe ad=erse e..ectA drug interactionsA and regimen comple@ity ; Is the length or course o. therapy appropriate ; 5. A pro"lem e@ists. '. More in.ormation is needed .or a determination. *. No pro"lem e@ists or an inter=ention is not needed.

5.

A pro"lem e@ists.

herapeutic duplication

Are there any therapeutic duplications ;

'. More in.ormation is needed .or a determination. *. No pro"lem e@ists or an inter=ention is not needed.

Drug allergy Intolerance

Is the patient allergic to or intolerant o. any medicines <or chemically related medications> currently "eing ta$en ; Is the patient using any method to alert health care pro=iders o. the allergy(intolerance <or serious medical pro"lem> ;

5. '. *.

A pro"lem e@ists. More in.ormation is needed .or a determination. No pro"lem e@ists or an inter=ention is not needed.

Ad=erse Drug +=ents

Are there symptoms or medical pro"lems that may "e drug induced ; What is the li$elihood that the pro"lem is drug related ;

5. '.

A pro"lem e@ists More in.ormation is needed determination. .or a

*. No pro"lem e@ists or an

inter=ention is

not needed. Are there drug:drug interactions ; Are they clinically signi.icant ; Are any medications contraindicated<relati=ely or a"solutely> gi=en patient characteristic and current(pass disease states ; Are there drug:nutrient interactions ; Are they clinically signi.icant ; Are there drug:la"oratory test interactions ; Are they clinically signi.icant ; Is the patientCs current use o. social drugs pro"lematic ; )ocial or Recreational Drug /se %ould the sudden decrease or discontinuation o. social drugs "e related to patient symptoms <e.g.A 0ithdra0al> ; 5. '. *. A pro"lem e@ists. More in.ormation is needed determination .or a 5. '. *. A pro"lem e@ists. More in.ormation is needed .or a determination. No pro"lem e@ists or an inter=ention is not needed.

Interactions : Drug:drugA Drug:Disease Drug:nutrientA and Drug:#a"oratory est

No pro"lem e@ists or an inter=ention is not needed. A pro"lem e@ists. More in.ormation is needed determination .or a

-ailure to Recei=e herapy

Has the patient .ailed to recei=e medication due to system error or noncompliance; Are there .actors hindering the achie=ement o. therapheutic e..icacy;

5. '.

*. No pro"lem e@ists or an inter=ention is not needed.

5. Is the chosen medication<s> cost e..ecti=e; '. -inancial Impact Does the cost o. drug therapy represent a .inancial hardship .or the patient ; *. Does the patient understand the purpose o. his or her medication<s>A ho0 to ta$e it and the potential side e..ect o. therapy ; 0ould the patient "ene.it .rom education tool <e.g.A 0riten patient education sheetsA 0allet cards and reminder pac$aging> ; 5. '.

A pro"lem e@ists. More in.ormation is needed determination .or a

No pro"lem e@ists or an inter=ention is not needed. A pro"lem e@ists. More in.ormation is needed determination .or a

Patient ,no0ledge o. Drug herapy

*. No pro"lem e@ists or an inter=ention is not needed.

D)(* THE)AP+ P)-B E' IST /DTP 0

PA I+N Date : PHARMA%I) :

#O%A ION(ROOM : Pro!lem Action/Inter1ention Date Pro!lem Action/Inter1ention

PHA)'A&IST2S &A)E P AN /P&P0 PA I+N : Pharmacotherape%tic *oal )ecommendations for therapy PHARMA%I) 'onitoring Parameter/s0 : 'onitoring #re3%ency

#O%A ION(ROOM : Health &are Need Desired Endpoint/s0

PHA)'A&IST2S &A)E P AN '-NIT-)IN* ,-).SHEET /P&P',0 PA I+N : PHARMA%I) : Date/Time Desired Endpoint/s0 'onitoring #re3%ency

#O%A ION(ROOM : Pharmacotherape%tic *oal 'onitoring Parameter