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C.

PATIENT CARE DURING HOSPITALIZATION

A. PATIENTS DATA
Name: Your name (abbreviation), then case number Enti Hariadha (EH-1)
Sex : Race : Age :
Height : Weight : BMI:
Admission Date: Discharged Date:

B. CHIEF COMPLAINTS

C. HISTORY OF PRESENT ILLNESS

D. PAST MEDICAL HISTORY

E. PAST MEDICATION HISTORY


Name of drugs Dose Freq Route Indication

F. FAMILY HISTORY

G. SOCIAL HISTORY

H. ALLERGY

I. PHYSICAL AND LABORATORY EXAMINATION

J. WORKING DIAGNOSIS

K. DIFFERENTIAL DIAGNOSIS

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L. MANAGEMENT PLAN
..................................

INVESTIGATIONS
................................

M. THE RESULTS OF LABORATORY INVESTIGATIONS


Nor
Para
Uni mal
meter
ts ran
s
ge
Full Blood Count
WBC x10 4.0-
9
/L 11.
0
Hb g/d 11.
L 5-
15.
5

2
RBC x10 4.2-
9
/L 5.4
Hct % 36.
0-
52.
0
Plt x10 150
9
/L -
400
Electrolytes
Sodiu mm 135
m ol/ -
L 145
Potass mm 3.5-
ium ol/ 5.0
L
Calciu mm 2.1
m ol/ 4-
L 2.5
8
Correc mm 2.1
ted Ca ol/ 4-
L 2.5
8
Phosp mm 0.8-
hate ol/ 1.4
L 5
Magn mm 0.7-
esium ol/ 1.3
L
Chlori mm 96-
de ol/ 106
L
Coagulation profile
PT sec 10-
ond 13.
s 5
APTT sec 26-
ond 42
s
INR <1.
5
Renal Profile
Urea mm 1.7-
ol/ 8.3
L
SCr um 64-
ol/ 122
L

3
CrCl ml/ 80-
min 120
Liver Profile
Total g/L 66-
Protei 87
n
Albu g/L 35-
min 50
T. um <20
Biliru ol/
bin L
ALT IU/ <32
L
AST IU/
L
ALP IU/ 53-
L 141
Cardiac Profile
CK IU/ 24-
L 195
Trop- <0.
T 1
LDH IU/ 0-
L 248
Lipid Profile
C- mm <5.
Total ol/ 7
L
C- TG mm <1.
ol/ 7
L
C- mm >1.
HDL ol/ 7
L
C- mm <3.
LDL ol/ 9
L

Blood Glucose
Dat
Time Mmol/L Remarks
e

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N. Vital Signs Chart
Date Time Temperature Blood Heart RR/ Pain
Pressure Rate SPO2 score

O. CULTURE & SENSITIVITY TEST


Date Sample & Test Result

P. PROGRESS NOTES
Date Subjective Objective Assessment Plan
Medical plan:

Medication plan:

Other pan:

Q. CURRENT MEDICATIONS
Date
Drug Regimen Drug Class/ Indication Started Stoppe
d
Antibiotics (it is just an example)

Diuretics (it is just an example)

Anti-hypertensive (it is just an example)

Electrolytes (it is just an example)

Anti-epileptics (it is just an example)

Topical Application (it is just an example)

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Others

R. DISCHARGED MEDICATIONS
Date
Drug Regimen Drug Class/ Indication Started Stoppe
d
Antibiotics

Diuretics

Anti-hypertensive

Electrolytes

Anti-epileptics

Topical Application

Others

S. FINAL DIAGNOSIS

T. PHARMACEUTICAL CARE ISSUES


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Date:
Pharmaceutical Care Issue (1):

Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care Issue (2):

Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care Issue (3):

Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care issue (4):

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Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care issue (5):

Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care issue (6):

Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

Date:
Pharmaceutical Care issue (7):
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Pharmacist Recommendation:

Outcome:

Monitoring:

Evidence:

How to write a reference : Follow APA style

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