Professional Documents
Culture Documents
Clerking Case
Clerking Case
A. PATIENTS DATA
Name: Your name (abbreviation), then case number Enti Hariadha (EH-1)
Sex : Race : Age :
Height : Weight : BMI:
Admission Date: Discharged Date:
B. CHIEF COMPLAINTS
F. FAMILY HISTORY
G. SOCIAL HISTORY
H. ALLERGY
J. WORKING DIAGNOSIS
K. DIFFERENTIAL DIAGNOSIS
1
L. MANAGEMENT PLAN
..................................
INVESTIGATIONS
................................
2
RBC x10 4.2-
9
/L 5.4
Hct % 36.
0-
52.
0
Plt x10 150
9
/L -
400
Electrolytes
Sodiu mm 135
m ol/ -
L 145
Potass mm 3.5-
ium ol/ 5.0
L
Calciu mm 2.1
m ol/ 4-
L 2.5
8
Correc mm 2.1
ted Ca ol/ 4-
L 2.5
8
Phosp mm 0.8-
hate ol/ 1.4
L 5
Magn mm 0.7-
esium ol/ 1.3
L
Chlori mm 96-
de ol/ 106
L
Coagulation profile
PT sec 10-
ond 13.
s 5
APTT sec 26-
ond 42
s
INR <1.
5
Renal Profile
Urea mm 1.7-
ol/ 8.3
L
SCr um 64-
ol/ 122
L
3
CrCl ml/ 80-
min 120
Liver Profile
Total g/L 66-
Protei 87
n
Albu g/L 35-
min 50
T. um <20
Biliru ol/
bin L
ALT IU/ <32
L
AST IU/
L
ALP IU/ 53-
L 141
Cardiac Profile
CK IU/ 24-
L 195
Trop- <0.
T 1
LDH IU/ 0-
L 248
Lipid Profile
C- mm <5.
Total ol/ 7
L
C- TG mm <1.
ol/ 7
L
C- mm >1.
HDL ol/ 7
L
C- mm <3.
LDL ol/ 9
L
Blood Glucose
Dat
Time Mmol/L Remarks
e
4
5
N. Vital Signs Chart
Date Time Temperature Blood Heart RR/ Pain
Pressure Rate SPO2 score
P. PROGRESS NOTES
Date Subjective Objective Assessment Plan
Medical plan:
Medication plan:
Other pan:
Q. CURRENT MEDICATIONS
Date
Drug Regimen Drug Class/ Indication Started Stoppe
d
Antibiotics (it is just an example)
6
Others
R. DISCHARGED MEDICATIONS
Date
Drug Regimen Drug Class/ Indication Started Stoppe
d
Antibiotics
Diuretics
Anti-hypertensive
Electrolytes
Anti-epileptics
Topical Application
Others
S. FINAL DIAGNOSIS
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care Issue (2):
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care Issue (3):
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care issue (4):
8
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care issue (5):
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care issue (6):
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
Date:
Pharmaceutical Care issue (7):
9
Pharmacist Recommendation:
Outcome:
Monitoring:
Evidence:
10