Anda di halaman 1dari 12

MODUL

PATIENT DATABASE

Demographic and Administration Information :


Name : Patient ID : Room No. :
Address : MD :
Age : Pharmacy :
Weight : Race : Sex :
Height : Religion :
MRS : Occupation :
KRS : Status pasien :
History of Present Illness :
Past Medical History/Surgery :
Family and Social History :
Life Style :

Acute and Chronic Medical Problem


No Problem Nilai normal Data serum Concentration (Tanggal)

DATA KLINIK PASIEN


DATA KLINIK TANGGAL
YANG
PENTING
DATA LABORATORIUM PASIEN
DATA TANGGAL
LABORATORIUM NORMAL
(YANG PENTING)

PEMERIKSAAN LABORATORIUM RADIOLOGI / PATOLOGI ANATOMI / MIKROBIOLOGI

Tanggal Jenis pemeriksaan Hasil Pemeriksaan Analisis dari Farmasi (terkait dg


penggunaan obat yang diberikan)

Konsultasi Dokter Spesialis Lain di Ruangan

Tanggal Konsul ke – dari Problem medis Intervensi / Tindak lanjut


PROFIL TERAPI SELAMA MRS
JENIS OBAT Tanggal Pemberian Obat (mulai MRS)
N Regimen
Nama dagang /
o. Dosis
Generik

Terapi farmasi saat ini

Obat Jadwal Masalah Medis & Tindak


Durasi Tanggal
Pemberian Masalah Lanjut
Nama/Dosis/Kekuatan/Rute Mulai-Stop
Obat Kefarmasian
1.
2.
3.

Allergies/Intolerances: Social Drug Use Cost Meds/month


Alcohol : (-) Insurance : no yes
Allergen Reaction Caffein : (-) Copay : (-)
Tobacco : (-) Medicaid : (-)
(-) (-) Annual income: (-)
Rekomendasi jadwal pemberian obat (An Example)
Time Line : Circle actual administration and record appropriate medications and meals below

Dini hari Pagi hari Siang hari Malam


hari

11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
10

Ket : # diberikan 15 menit sebelum makan


DRUG THERAPY ASSESSMENT WORKSHEET (DTAW)

Type of problem Assessment Presence of Drug-Related Problem Comments/Notes

Are there drug without a 1. A problem exists.


medical indication ?
2. More information is needed for
a determination.
Are any medication unidentified (are any
Correlation between unlabeled or are any-prior to admission 3. No problem exists or an intervention is
Drug Therapy and clinic visit-unknown) ? not needed.
Medical Problem

Are there untreated medical conditions ?

Do they require drug therapy ?

What is the comparative efficacy of the 1. A problem exists.


chosen medication(s) ?
2. More information is needed for a
Appropriate Drug determination.
Selection What is the relative safety of the chosen
medication(s) ? 3. No problem exists or an intervention is
not needed.

Has the therapy been toilered to this


individual patient ?

Are the prescribed dose and dosing


Drug regimen frequency appropriate-within the usual 1. A problem exists.
therapeutic range and/or modified for
patient factors ? 2. More information is needed for a
determination.
Is the route/dosage form/mode of
administration appropriate, considering 3. No problem exists or an intervention is
efficacy, safety, convenience, patient not needed.
limitation, and cost ?

Are doses scheduled to maximize


therapeutic effect and compliance and to
minimize adverse effect, drug
interactions, and regimen complexity ?

Is the length or course of therapy


appropriate ?

1. A problem exists.

2. More information is needed


Therapeutic Are there any therapeutic duplications ? for a determination.
duplication
3. No problem exists or an
intervention is not needed.

Is the patient allergic to or intolerant of 1. A problem exists.


Drug allergy any medicines (or chemically related
Intolerance medications) 2. More information is needed
currently being taken ? for a determination.

Is the patient using any method to alert 3. No problem exists or an intervention is


health care providers of the not needed.
allergy/intolerance (or serious medical
problem) ?

1. A problem exists
Are there symptoms or medical problems
that may be drug induced ? 2. More information is needed for a
Adverse Drug
determination.
Events
What is the likelihood that the problem is
drug related ? 3. No problem exists or an intervention
is not needed.

Are there drug-drug interactions ? 1. A problem exists.


Are they clinically significant ?
Are any medications 2. More information is needed for a
Interactions :
contraindicated(relatively or absolutely) determination.
Drug-drug,
given patient characteristic and
Drug-Disease
current/pass disease states ? 3. No problem exists or an intervention is
Drug-nutrient, and
not needed.
Drug-Laboratory
Are there drug-nutrient interactions ?
Test
Are they clinically significant ?

Are there drug-laboratory test


interactions ?
Are they clinically significant ?

Social or
Recreational Is the patient’s current use of social drugs 1. A problem exists.
Drug Use problematic ?
2. More information is needed for a
Could the sudden decrease or determination
discontinuation of social drugs be related
to patient symptoms (e.g., withdrawal) ? 3. No problem exists or an intervention is
not needed.

1. A problem exists.
Has the patient failed to receive
medication due to system error or 2. More information is needed for a
Failure to Receive noncompliance? determination
Therapy
Are there factors hindering the 3. No problem exists or an intervention
achievement of therapheutic efficacy? is not needed.

1. A problem exists.
Is the chosen medication(s) cost
effective? 2. More information is needed for a
Financial Impact determination
Does the cost of drug therapy represent a
financial hardship for the patient ? 3. No problem exists or an intervention is
not needed.

Does the patient understand the purpose 1. A problem exists.


of his or her medication(s), how to take it
Patient Knowledge and the potential side effect of therapy ? 2. More information is needed for a
of Drug Therapy determination

would the patient benefit from education 3. No problem exists or an intervention is


tool (e.g., writen patient education sheets, not needed.
wallet cards and reminder packaging) ?
DRUG THERAPY PROBLEM LIST (DTPL)

Date Action/Intervention Action/Intervention


Medication Problem Date Medication Problem
by Pharmacy by Pharmacy
PHARMACIST’S CARE PLAN (PCP)

Pharmacotherapeutic Recommendations Monitoring Monitoring


Health Care Need Desired Endpoint(s)
Goal for therapy Parameter(s) Frequency
PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PCPMW)

Pharmacotherapeutic Monitoring Monitoring Date/Time Note


Desired Endpoint(s)
Goal Parameter Frequency
LEMBAR KONSELING
No Hari dan Sasaran Uraian Rekomendasi / Evaluasi terhadap Evaluasi terhadap
tanggal konseling Informasi/Saran Efektivitas, termasuk Efek Samping Obat
Kepatuhan
1
2
3
4
5