FORM SOAP

PHARMACEUTICAL CARE

PATIENT PROFILE

Tn. / Ny.

Jenis Kelamin : Tgl. MRS :

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

Presenting Complaint :

Diagnosa kerja :

Diagnosa banding :

➢ Relevant Past Medical History :

Drug Allergies :
Tanda-tanda Vital tgl tgl tgl tgl tgl tgl
Tekanan darah
Nadi
Suhu
RR
 Medication
No. Nama Obat Indikasi Dosis yang Dosis Terapi
digunakan (literatur)

8
9

10

11

12

13

14

15
 LABORATORY TEST
Test (normal range) 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 (3,5-5,0 mEq/L)

No Further Information Required Alasan

 Problem List (Actual Problem)
Medical Pharmaceutical

PHARMACEUTICAL PROBLEM

Subjective (symptom)

- Objective (signs)
Assesment (with evidence)

Plan (including primary care implications)

Monitoring
• Efektivitas

• Efek Samping Obat