CP2- New

Pin.1/13

PHARMACOTHERAPY REVIEW (CP2) Pharmacy Department, Hospital Seberang Jaya Ward: ______ Bed: ______ Date of clerking: ____________  A.

ALLERGY:

DEMOGRAPHIC DATA

Name :

MRN :

Chief Complaint:

History of Present Illness:

Past Medical History:

Review of System:

Past Medication History:

Social/ Family History:

BP: PR: RBS:

Age :

Gender : M / F Race : M / C / I / Others

RR: T: SpO2:

Ht/Wt :

DOA :

Smoking  Alcohol Drug Abuse Pregnant

Compliance Evaluation:

Diagnosis/Surgical Diagnosis/Surgical Procedure:

B.

LABORATORY INVESTIGATION Date

1

2

3

4

5

6

7

8

9

Normal Range C B F

lei f o r P l a n e R / E S U B

T F L

. g a o C E C

G B A

TWBC Hb Platelet

4 –11 x10/L 11.5-16.5 g/100mL 150-400 x10/L

Urea Na+ K+ ClSCr CrCl Ca2+ Mg2+ PO4-

1.7-8.3 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 96-106 mmol/L 64-122 umol/L 105-150 ml/min 2.1-2.6 mmol/L 0.7-1.3 mmol/L 0.8-1.45 mmol/L

Albumin T.Bilirubin T.Bilirubi n T.Protein ALP ALT

35 – 50 g/L <20 umol/L 66 – 87 g/L 53 – 141 u/L <32 u/L

PT APTT INR

10-13.5 sec 26 – 42 sec <1.5

CK LDH AST

24 – 195 u/l 0 – 248 u/l <37 u/l

pH pCO2 pO2 HCO3 O2 sat

7.35-7.45 35-45mmHg 72-100mmHg 22-29mmol/L 90-95%

RBS

< 11 mmol/L

sr e ht O

O/ I

Input Output Balance

C

&

S

Date (Sampling)

Date (Result)

Source/Samp le

Microorganism Microorgani sm

Sensitivity Sensitivi ty

Resistance

10

C.

WARD MEDICATION

Drug/Regimen

Start Date

Stop Date

Indication/ Reason for Change

Reconciliation Note S-Stopped / W-Withold/ D-Continue on Discharge (+Duration)

S IC T IO BI T N A

S N IO T A IC D E M R E H T O

D.

PHARMACEUTICAL CARE PLAN

Date

Goal of Therapy

Pharmacist’s Sign

& Stamp:

Evidence based Medication

Reviewed by:

Monitoring