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Hospital

Pharmacy Laboratory 2013



_____Name___________________________________

2___Ph

Date______________


Activity 5
Patient Medication Profile


1. Read the Physician Order Sheet.
2. Fill out the Patient Medication Profile.

PROCEDURE IN CREATING AND UPDATING A PATIENT MEDICATION PROFILE


Demographics:
1. Fill out the information needed in the demographics using black ink, except working diagnosis (pencil), diet (pencil) and if with allergy
(red ink). Working diagnosis and diet is written in pencil because they are frequently modified and the most current information should
be reflected in the PMP.

Standing Medications:
1. All new standing medication orders are immediately written in the PMP.
2. The date and time ordered can be seen in the physician order sheet before the medication order and should be written in black ink.
3. The name of medication should include both generic and brand name and are written in black ink. The brand name reflected should be
the actual brand given to the patient.
4. The dose, route and frequency should be transcribed to the PMP in exactly the same way as the physicians order and are written in
black ink. If the actual preparation used is different from the medication order and was just modified to deliver the required dose, the
stock dose must be indicated at the right portion under the name-of-medication column using red ink. If the physician indicated to
give two or more units of a particular dosage form (e.g. 2 capsules), the quantity should be indicated in red ink immediately under the
dose column.
5. The date and time started can be seen at the medication administration record as documented by the nurses or physician and is
written in black ink. Should the medication be revised (e.g. increased dose, decreased dose, change in route of administration, etc.),
the very first dose of that particular generic drug will be carried over to the revised regimen. Projected start date will be written in
pencil under remarks column.
6. The date and time of last dose for discontinued and shifted medications can be seen at the medication administration record and is
written in black ink. However, for revised medications (e.g. increased dose, decreased dose, change in route of administration, etc.) the
last dose for the particular regimen will be written in pencil indicating that the drug is not discontinued or shifted and is still being
administered only with different route, strength or frequency. Projected date of last dose should likewise be written in pencil.
7. Discontinued, shifted or revised medications should be striked with a red ink starting from the name-of-medication to frequency
column.
8. Remarks would indicate medications that are discontinued, shifted or revised in red ink; the antibiotic days in pencil; and other
pertinent instructions (NPO, projected initial dose, etc.) also in pencil. The antibiotic days must be updated daily.
9. Techniques of administration should be written in red ink (e.g. on the right portion under the name of medication column in glass
of paper).
10. Duration of therapy must be written down in red ink under the frequency column
11. Erroneous entries will be corrected by putting a strike across the words in red ink and write the phrase wrong entry beside it.
Superimpositions or usage of correction fluid, friction pen, correction tape are not allowed.

PRN Medications:
1. PRN medications follow the same rule as standing medications. In addition, indication for PRN usage is indicated in red ink on the right
portion under the name of medication column.
Stat Medications:
1. Stat medications follow the same rule as standing medications, except that the date and time of last dose will be left blank because stat
medications are given once only. A diagonal bar will be placed instead.
2. The date and time of dose given should be written in red ink at the remark column.


IV Medications/ IV Incorporations/Parenteral Nutritions:
1. IV Medications/IV Incorporations/Parenteral nutrition follows the same rule as standing medications except that the date and time of
last dose will be left blank.
2. For IV fluids, write the volume and flow rate in black ink.
3. The rate of infusion in mL/hr must also be computed.

2013 Hospital Pharmacy Laboratory



SAINT THOMAS HOSPITAL
Sampaloc, Manila, Philippines

PHYSICIAN ORDER SHEET


PATIENTS NAME: ARGB AGE: 32 y/o WEIGHT: 56 Kg HEIGHT: 156 cm ALLERGY: NKA

Rm No: 110B

Admission Date: January 12, 2013

Ward: OB-GYN

Admitting Impression: G3P2 (2002) Pregnancy uterine 40-41 wk AOG, cephalic in labor

Doctor: Dr. Lopez

12 Jan.

Nurse:

Diet: NPO-TPN

PNSS 1L + 10 units Oxytocin x 8 hours

Monitor VS q1h

Pharmacist:

Monitor fetal heart, and uterine contractions q 15mins and record

13 Jan.

Hook to O2 supplementation 2-3cpm/cannula

Give Methergin 200 mcg/IV now

Give Methergin 0.125mg/tab PO q8h x 5 days

Give Cefuroxime 500mg/cap PO q 12h

PNSS 1L + 10 units Oxytocin to consume then shift to PNSS 1L IV x 8hrs

Shift Methergin tab to Methergin 0.125mg/IV q6h x 3 days

Revise Cefuroxime cap to Cefuroxime 500mg/IV q8h x 3 more doses

Paracetamol 500mg/tab PO now

Diphenhydramine 50mg PO now

Give 1U pRBC at 3:45 pm

Give Metronidazole 500mg IV q 12h x 2 doses

8:00 AM

10:00 AM

2:00 PM

3:00 PM

10:00 PM

14-Jan

12:00 AM

Give Nalbuphine 10mg/IV now

1:30 AM

Give Ranitidine 50mg/IV now

1:35 AM

Give Metoclopramide 10mg/IV now

2:00 AM

Give PLRS 1L IV x 8 hours

Manual extraction of placenta for histopath

Diet: May have clear liquids once fully awaken then progressive diet

Monitor VS q2h and record

5:00 AM

Give Cefuroxime 1.5g IV now

6:00 AM Paracetamol (Aeknil) 300mg IV now then q4h PRN for T> 37.8 C
o

Hospital Pharmacy Laboratory 2013



MEDICATION ADMINISTRATION RECORD

DRUG
Methergin 0.125mg
tab q8

TIME

12 JAN

6-2

2-10

6-2
Cefuroxime 500mg
cap q12

2-10
10-6
6-2

Methergin 0.125 mg
IV q6h x 3 days

2-10
10-6
6-2

Cefuroxime 500mg
IV x 3 more doses

2-10
10-6
6-2

Metronidazole
500mg IV q12h x 2
doses

2-10
10-6
6-2

Paracetamol (Aeknil)
300 mg IV now then
o
q4 PRN T>37.8 C

2-10
10-6

6-2

2-10
10-6

PNSS +10 units


Oxytocin @ 9AM Cja
PNSS +10 units
Oxytocin @ 5PM Gma

6-2

2-10
10-6
6-2

2-10
10-6

14 JAN

11 AM Cja

10-6

13 JAN

Shifted
13 Jan 2 PM

11 AM Cja


Revised
13 Jan
2PM

15 JAN


5 AM Cja

5 AM Cja
11AM Cja

5 AM Cja
11AMCja

5 PM Mdb

5 PM Mdb

5 PM Mdb

11 PM Gma

11 PM Gma

11 PM Gma

11 AM Jd

7 PM Mdb

3 AM Gma

10 AM Jd



Completed
14 Jan 11AM

10:20 PM Mdb

Completed
14 Jan 10AM

6:10 AM Jd

PNSS +10 units


Oxytocin @ 9AM Cja

PNSS @ 5PM Gma

PNSS +10 units


Oxytocin @ 1AM Mdb
Methergin 200mcg/IV
@10:15 AM Cja
Paracetamol 500mg
@320 PM Gma

Nalbuphine
10mg IV @
12:10 AM
Mdb

PLRS 1L
@ 2AM
Mdb

Ranitidine 50mg IV @
1:40 AM Mdb

Diphenhydramine 50
mg @320 PM Gma

Metoclopramide 10 mg
IV @ 1:40 AM Gma

2013 Hospital Pharmacy Laboratory






Hospital Pharmacy Laboratory 2013



2013 Hospital Pharmacy Laboratory