INTRODUCTION TO

CLINICAL PHARMACY
John Kenneth B. Llena, RPh
PharCare5 Laboratory
CLINICAL PHARMACY
A set of function that promotes SAFE, EFFECTIVE and
ECONOMICAL use of medications

Patient-centered and drug-oriented

A component of pharmaceutical care

PHARMACEUTICAL CARE

Direct, responsible provision of medication related care for

the purpose of achieving a definite outcome that improves a
patients quality of life

Involves the process through which a pharmacist cooperates

with a professional in designing, implementing and
monitoring a therapeutic plan that will produce specific
therapeutic outcome
CLINICAL PHARMACISTS

Ward Pharmacists

Involved in activities promoting the health of the patients

ROLES OF CLINICAL PHARMACISTS

Counseling

Drug Interactions

Research

Monitoring
DOCUMENTATION

Not documented, not done.

For tracking purposes, reference and evidence of work

Means of communication
PATIENT CHART
PATIENT CHART

A collection of documents that provides an account of each

episode in which a patient visited or sought treatment,
received care or a referral for care from a health care facility

A narrative or record of past events and circumstances that

are or may be relevant to a patient's current state of health
PATIENT CHART

A confidential record usually held by the facility and

information in it is released only to patient or with the
patients written permission

A collection of papers held in a folder but may be

computerized
1. PATIENT DEMOGRAPHICS

Patient Name
Age
Gender
Status
Address
Occupation
Religion
2. CHIEF COMPLAINT

A brief statement of the complaint or incident that prompted

medical consultation

Im having pain in my leg.

Sobrang sakit ng ulo
Laging nahihilo
3. HISTORY OF PRESENT ILLNESS

A detailed chronologic narrative, as much as possible in the

patients own words, of the development of the current
health problem from its onset to the present

He woke up at 7:15 AM and went to the bathroom to brush his

teeth. While walking from the bathroom to the kitchen, he noticed
general weakness and had trouble saying good morning to his
son. His son immediately brought him to the ER. While in the ER,
he started to have a right-sided facial droop.
4. PAST MEDICAL HISTORY

A narrative of prior illnesses, their treatments and sequelae

medical; surgical; obstetric/gynecologic; and psychiatric

3 years ago, Lucy was diagnosed as lupus carrier. Since the

diagnosis, Lucy has been taking Warfarin and she expects to
maintain Warfarin therapy for life. Her condition has
exacerbated a series of endotheliopathies, predisposing Lucy
to retinal microvascular occlusion.
5. FAMILY HISTORY

Present health or cause of death of parents, brothers, sisters,

with special attention to hereditary disorders

Documents presence or absence of specific illnesses in

family
6. SOCIAL HISTORY

Marital status
Past and Present Occupations
Travel
Hobbies
Stresses
Diet
Habits
Use of Tobacco, Alcohol or Drugs
7. MEDICATIONS, ALLERGIES,
IMMUNIZATIONS

List of any medications, both prescription drugs and over-

the-counter medications, home remedies, vitamins, and
supplements as well
8. REVIEW OF SYSTEMS

An exhaustive survey of symptoms or diseases, organized by

body system, not covered in previous parts of the history

A system-by-system review of body functions, organized and

complete examination of patients organ system as part of the
work-up plan when the patient is first seen by a physician

Gathered through verbal history or written check-off

questionnaire
9. PHYSICAL EXAMINATION

An evaluation of the body, and its functions using

INSPECTION, PALPATION, PERCUSSION and
AUSCULTATION

Actual visual and hands-on findings

10. LABORATORY TESTS

A generic term for any test regarded as having value in

assessing health or disease states
11. THE PROBLEM LIST

Any health care condition that requires diagnostic,

therapeutic or education action

Physicians assessment/Working diagnosis

List of all identified disease condition.

12. THE PLAN

List of physicians orders to address the problem list related

to the health of the patient
 SUBJECTIVE vs OBJECTIVE
Subjective Information that cannot be measured directly
and may not always be accurate or reproducible
(Demographics, History)

Objective Can be measured. They are observable and are

not influenced by emotion or prejudice (Vital signs)
PATIENT'S MEDICAL CHART
PATIENTS MEDICAL CHART

Confidential document that contains detailed and

comprehensive information on an individual and the care
experience related to that person
A. ADMISSION REPORT

Patient Demographics

Facts relative to Admission

Attending Physician, Date and Time of Admission, Room
Number, Admitting Diagnoses, Anticipated Procedures

Consent for Admission

B. CONSENT OF TREATMENT
STATEMENT

When signed, the patient is put under the control of the

hospital for its care and under the control of the attending
physician for such physicians care
C. ATTESTATION STATEMENT

Requirement for Insurance

May be separate or incorporated in the Admission Report

Contains details for reimbursements

D. MEDICAL HISTORY

Assist with diagnosis, treatment decisions and establishment

of trust and rapport between patient and medical
professional

CC, HPI, PMH, Medication History, SH, FH, ROS

E. PHYSICIANS ORDERS

Doctors Order Sheet

Marching Orders as to the tests, medication and treatments

F. PHYSICAL EXAMINATION REPORT

Palpation

Auscultation

Inspection

Percussion
G. PROGRESS NOTES

Includes regular notes on the patients status by the

interdisciplinary team

Contains field of subjective and objective findings assessment

and plan, and diagnostic with therapeutic information and
planned date for review
H. PATHOLOGY REPORT

Documents of diagnosis determined by examining cells and

tissues under a microscope
I. CONSULTATION REPORT

Notes from specialized diagnosticians or care providers

J. VITAL SIGNS GRAPHICS

Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Urine
Stool
K. MEDICATION AND
ADMINISTRATION RECORD

Medication and Treatment Sheet

Document which contains the name of drug, time of

administration of the drug to the patient and initials of the
person who administered it
M. CONSENTS

Written permissions signed by patient for procedures, tests

or access to charts

May also contain releases such as HAMA

N. REFERRAL FORM

To direct source for help or information

To submit to a medical specialist for arbitration, decision or

examination
O. FLUID INTAKE and OUTPUT
CHART

Intake measurable fluid that goes into the patients body

Water, soup, juices, ice cream, gelatin, IV fluids

Output measurable fluid that comes from the body

Urine, drainage, vomit and stools
P. DISCHARGE REPORTS

Final instructions for the patient and reports by the care team
before the chart is closed and stored following patient
discharge

Summation of all activities during the patients course of

hospitalization
Q. PATIENT MEDICATION PROFILE

A comprehensive written summary of all regular medicines

taken by the patient

Standing Medications
Stat Medications
PRN Medications
Intravenous Fluids Medications
OTHERS PARTS
Radiology Reports
Anesthesia Records
Operative Reports
Nurses Reports
Surgical Forms
Laboratory Report
Physical Therapy Evaluation
Respiratory Therapy Evaluation
Special Reports
 END
THANK YOU!