Clinical pharmacist intervention note in patient file

Patient named:- Department: Hemodialysis

By reviewing patient medications it is found that patient has the following

MedicationRelated problem(s):
1 □ inappropriate indication 8
□ Duplication
2
□ inappropriate dose or regimen 9
□ Discontinuation of needed medication
3
□ Compliance/ nurse management problem 10
□ Therapeutic failure
4
□ Adverse Medication reaction 11
□ Untreated medical condition
5 12
□ Medications interaction:- □Lack of necessary Medication monitoring
□Medication □Food □Lab □Habits□Herb
6
□ Contraindication 13
□ Need for additional Medication therapy
7
□ unnecessary medication 14
□ others
Recommendations:
Inappropriate Regimen
Patient Only Doing Hemodialysis 3.5 hour Twice A week The Guidelines
Recommended
hemodialysis treatment lasts about four hours and is done three times per week.

Lack Of Necessary Monitoring

Patient at High Risk Of Animia And Not Monitoring So we Recommend To
Monitoring anemia every 3 months If Less Than 8 mg / dl Need RBC Transfusions
And Ifhemoglobin Less Than 10 We Recommend To Add Epoetin alfa Starting dose:
50–100 units/kg three times per weekly Subcutaneous dosage requirement is
typically 30% less than intravenous dosage requirement.

Lack Of Necessary Monitoring Electrolyte , Minerals ( Ca , Phosphate ) And PTH '

VIT D
So We Recommend TO Monitoring
Electrolyte After Dialysis
Ca , phosphate Every 3 M
PTH Every 3-6 M

Need Additional Medication Therapy

Need To Give HBV Vaccine For His Family To Protect Him

11
 Patient risk HTN , History Of Smoking , Taking NSAID
References ACCP Principle and Practice Pharmacotherapy
KIDGO Guidline
Physician comments
NO PHYSICAN

Clinical pharmacist daily intervention note

Date Description Recommendations Acceptance
(Mention reason if
rejected)

Twice Patient Rejected Red Marker

Weekly Inappropriate Regimen
age 38
Wight Befor D 53 kg Patient Only Doing Hemodialysis 3.5
Wight After D 50 Kg hour Twice A week The Guidelines
has HBV Positive Recommended
Control Hypertension hemodialysis treatment lasts about
UnMonitoring four hours and is done three times
Electrolyte And Mineral per week.

Patient Medication
amlodipine And Lack Of Necessary Monitoring
Valsartan 10 / 160 1×1
Patient at High Risk Of Animia And
CARVIDLOL 6.25 mg 1×1
And Take Complement Not Monitoring So we Recommend To
Medicine Like Monitoring anemia every 3 months
VIT C
Iron Folic Acide If Less Than 8 mg / dl Need RBC
Vit B 12 Transfusions
Calcium Gluconate
And Ifhemoglobin Less Than 10 We
Recommend To Add Epoetin alfa
Starting dose: 50–100 units/kg three
times per weekly Subcutaneous
dosage requirement is typically 30%
less than intravenous dosage
requirement.

Lack Of Necessary Monitoring

Electrolyte , Minerals ( Ca ,
Phosphate ) And PTH ' VIT D
So We Recommend TO Monitoring
Electrolyte After Dialysis
Ca , phosphate Every 3 M
PTH Every 3-6 M

11
 Need Additional Medication
Therapy
Need To Give HBV Vaccine For
His Family To Protect them

A+B

11