MRM COLLEGE OF PHARMACY

THUMBAY HOSPITAL NEWLIFE

Patient Profile Form
Patient Name: IP No: Age: Gender: DoA:

Unit: Weight: Height: Add: DoD:

Reasons for Admission:

Patient Illness History(PIH): Patient Medication History(PMH):

Occupational & Social History:

Personal Habits Diet:

Addictions With Smoking: Alcohol: Any other:

Duration
Vital Data Day-1 Day-2 Day-3 Day-4 Day-5 Day-6 Day-7

Pulse Rate (beats/min)

B.P. (mm/Hg)

Resp.Rate (B/m)
o o

Temp ( C/ F)
Provisional Diagnosis:

Laboratory Investigations
Date Date Date Date Date Date
Hematology Normal. Range Hematology Normal Range

RBC count: MCV 76–100 fL

Male 4.3–5.9 ×1012/L MCH 27–33pg

12
Female 3.5–5.0 ×10 /L MCHC 33–37 g/dL

T.WBC 4–11 ×109/L PLTcount 150–450×109/L

N 40%–70%

L 20%–40% Renal function test

E 0%–8% S.Cr 0.6–1.2mg/dL

B 0%–3% BUN 8–20mg/dL

M 0%–11% Thyroid function tests

ESR TSH 0.4–5munits/L

Male 0–20mm/h FreeT3 80-220ng/dl

Female 0–30mm/h FreeT4 0.8-2.4ng/dl

Serum Date Date Date
Normal Range Date Date Date Liver Function Test
electrolytes
Na 135–145mEq/ ALT(SGPT) 0–35units/L

K 3.5–5mEq/L AST(SGOT) 0–35units/L

Cl 95–105mEq/L ALP 30–120 units/L

Ca-total 8.5–10.5mg/dL Bilirubin-T 0.1–1mg/dL

Ca-unbound 4.5–5.6mg/dL Bilirubin-D 0–0.2mg/dL

Lipid profile Albumin 3.3–4.8g/dL

Totalcholesterol <200mg/dL Globulin 2.3–3.5g/dL

HDL >40mg/Dl Cardiac biomarkers

Creatine
LDL 70–160mg/dL <150units/L
Kinase
Triglycerides 0–12 units/L
<150mg/dL CK-MB
(fasting)
Blood glucose cTnI <1.5ng/mL
Urine Date Date Date
FBS 70–99mg/dL Normal Range
analysis
PPBG <160mg/dL Physical

RBS <160mg/dL appearance

Yellow,straw,
HgbA1c <4–5.6% Color
amber
Miscellaneous Reaction 4.6–8.0

CRP – 0 1.6mg/dL Specific gr 1.001–1.035

Amylase 35–120units/L Chemical

Other Investigations: Albumin
Negative
Sugar Negative

Ketonebodies Negative

Bilesalts Negative

Bilepigments Negative

Microscopy
Epithelial
cells
Occasional
Puscells Occasional

Final Diagnosis: RBCs Occasional

Casts

Crystals

Others
 MANAGEMENT
Medication Chart

Days
Routeof Freq.
Drug Brand Name Generic Name Indication Dose 1 2 3 4 5 6 7 Discharge Medication
Admin
 MEDICATION HISTORY INTERVIEW

DEMOGRAPHIC DETAIL

Patient Name: Sex: DOB:

Consultation (Dept): Weight: Ward:

Admission: Height: Interview:

1) PRESCRIPTION MEDICATION: What medications are you having at the moment?

A) Present illness and past medical history?

B) Other drug prescribed previously (with dates if possible): what have you had in the past?

2) NON- PRESCRIPTION MEDICATION: Do you take any-thing that you buy from a shop
without a prescription (chemist, Health food store, super market)?
A) Currently being used:

B) Used previously (with dates if possible):

3) SOCIAL HABIT /DRUG: ask what and how much/many per week?
A) Smoking:

B) Alcohol:

C) Illicit drugs:

4) RESPONSE TO THE DRUG THERAPY:

A) Do you think your current medication is benefiting you?
If yes why? If no why?

B) Do you think your previous medication benefited you?

If yes why? If no why?

5) Do any of the things you buy without a prescription?

If yes, which ones?

6) What have you been told about your medicines and by whom?
7) ABOUT USING DRUGS AND SIDE EFFECTS:
A) Are you suffering any side effects now?
If yes, what are the side effects?

B) Which of your medicines do you think is causing the problems?

C) Have you suffered any side effects with previous drug treatments?
If yes, what are the side effects and the medication?

8) COMPLIANCE:
A) How do you remember to take your medication?

B) What do you do when you miss a dose?

9) WHAT MEDICINES WOULD YOU USUALLY TAKE FOR:

A) Headache:
B) Aches/pains and flu:
C) Hay fever:
10) Do you know if they would agree with your regular medications? If yes, who told you?

11) If ‘No’ then who would you ask?

A) Health worker:
B) Pharmacist/chemist:
C) Doctors:
D) Nurse:
E) Relative or friends:
F) Others, please specify:
G) No-one:
12) ANY OTHER PROBLEMS WITH YOUR DRUG THERAPY?

13) COMMENT:

14) RECOMMENDATIONS:

15) FOLLOW- UPS:

Address and contact no:
Medication Diary providing:
Patient information Leaflets providing:
Dates and Time:
NOTIFICATION OF SUSPECTED ADVERSE DRUG REACTION

Patient’s Name:……………………………………………………..……….Age:….…….Sex:………………
I.P. /O.P. No.:……………………….....................Unit:………………………………………………………..

Suspected Drug(s):……………………………………………………………………………………………...
Date of suspected drug(s) started:………………………………………………………………………………
Brief description of reaction:……………………………………………………………....................................
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..

Name of the reporting Doctor:………………………………………………………………………………….

Signature:……………………………………………………… Date:…………………………
AHM

DRUG INTERACTION DOCUMENTATION

Diagnosis:

Drugs involved:

Brief descriptive of drug interaction:

Case narrative:

Suggestions made:
Significance of drug interactions:
 Minor
 Moderate
 Major

Reference consulted:

Name of Clinical Pharmacists: Signature:

Name of Staff Incharge: Signature:

DRUG INFORMATION DOCUMENTATION FORM

Name of the enquirer: Dept:

Enquirer’s professional status: Physician / Clinical Pharmacists / Others

Current Medical Problems:

Relevant drug therapy:

If pregnant: First trimester / Second trimester / Third trimester

Mode of request:
 Direct access
 Telephone
 During ward rounds
 Others

Purpose of enquiry:
 Update knowledge
 Better patient care
 Others
Question category: Indication / Dosage administration / Efficacy / PK / Cost / Interactions / ADR / Drug therapy
/ Dosage adjustment / Others

Answer needed: Immediately / Within 24 hours / Within a day / Within 1-2 days

Answer given:Immediately / Within 24 hours / Within a day / Within 1-2 days

Information provided:

Reference:

Name of clinical pharmacists: Signature:

Name of staff: Signature

PATIENT COUNSELLING DOCUMENTATION

Type of patient: Inpatient / outpatient

Age: Sex:

Current medical problem:

Current medication:

Disease counseled :
Counselling steps followed:
 Case sheet reviewed
 Self-introduction done
 Purpose of counseling aid
 Initial drug related information obtained
 Patient was warned about taking OTC medications
 Counseling points summarized

Points covered during counseling session:

 Name and purpose of medication
 Dosage regimen
 Advice on missed dose
 Potential side effects
 DI
 Precautions to be taken
 Storage recommendations
 Lifestyle modifications

Any barriers involved: Yes/ no

If yes,
 Patient based
 Provider based
 System based

Time taken for counseling:

 Less than 10 min
 10-20 min
 More than 20 min

Counselling provided to:

 Patient
 Patients representative

If patients representative, give reason:

 Patient is unconscious
 Language problem
 Hearing problem
  Others

Counselling aids used:

 Pictograms
 Dummy inhaler device
 Spacer
 None

Counselling material provided:

 Patient information leaflet
 Pamphlets
 Product information leaflets
 None

Understanding of patient ascertained: Yes /No

Name of clinical pharmacists: Signature:

Name of patient: Signature:

 SOAP FORMAT
 SUBJECTIVE:

 OBJECTIVE:
 ASSESSMENT:

 PLANNING:
 Remarks:

Name of staff incharge :

Signature: