FORM SOAP

PHARMACEUTICAL CARE

PATIENT PROFILE

Tn. / Ny.

JenisKelamin : Tgl. MRS :

Usia : Tgl. KRS :
Tinggi badan :
Berat badan :

Presenting Complaint

Diagnosakerja :

Diagnosa banding :

 Relevant Past Medical History:

Drug Allergies:

Tanda-tanda Vital Satuan Tgl Tgl Tgl Tgl Tgl

Tekanandarah mmHg
 Nadi x/min
o
Suhu C
RR

MEDICATION
NO NAMA OBAT INDIKASI DOSIS YANG DOSIS TERAPI
. DIGUNAKAN (LITERATUR)
1.
2.
3.
4.
5.
6.

LABORATORY TEST
Test (normal range) Tgl Tgl Tgl
WBC (4000-10000/mm3)

Hb (L: 13-17 g/dL)

RBC (4-6x106/mm3)

Hct (L:40-54%)

PLT (150000-450000/mm3)

Gula darah puasa (76-110 mg/dL)

Gula darah 2 jam PP (90-130
mg/dL)
Cholesterol (150-250 mg/dL)

TG (50-200 mg/dl)

Uric acid (L:3,4-7 mg/dL)

Albumin (3,5-5,0 g/dL)

SGOT (0-35 u/L)

SGPT (0-37 u/L)

BUN (10-24 mg/dL)

Kreatinin (0,5-1,5 mg/dl)

Natrium (135-15 mEq/L)

Kalium (3,6-5,0 mEq/L)

No Further Information Required Alasan

1.

2.

3.

7
8

Problem List (Actual Problem)

Medical Pharmaceutical
1 1

2 2

3 3

4 4

5
5
6
6

PHARMACEUTICAL PROBLEM

 Subjective (symptom)

 Objective (signs)
 Assesment(berdasarkan Evidence)

 Plan (including primary care implication)

 Monitoring Efektivitas
 Efektivitas
 Efek Samping Obat

PARAF