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PATIENT DATABASE

Demographic and Administration Information


Name : Patient ID : Room No. :
Address : MD :
Age : Pharmacy :
Height : Weight: Race : Gender :
Admission Date : Religion :
Discharge : Occupation :

History of Present Illness: Vital Sign/Laboratory Data – Initial/Follow up

Date

RR
HR
Temp
BP

Hb
Leko
Tromb
PCV
Past Medical
History/Surgery : GDA
PH
pCO2
pO2
Family and Social History : HCO3
BE

K
Na
Cl

Eo
Baso
Lifestyle: Batang
Seg
Limf
Mono

Bl.Dir
Indir
TTT

SGOT
SGPT
BUN
SCr

Sesak
Batuk
Acute and Chronic Medical Data Serum Concentration
Problems :

Current Drug Therapy

Drug Prescribed Duration Start – Compliance/Dosing


Name/Dose/Strength/Route Schedule Stop Dates Issue

Medication PTA
Time Line: Circle actual administration times and record appropriate medications and meals
below.

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

Allergies/Intolerances: Social Drug Use Cost Meds/month


Alcohol : Insurance : Yes No
Allergen Reaction Caffein : Copay :
Tobacco : Medicaid :
Annual income:

Notes:
Patient : Tn. SH
Location/Room : Bedah/Gladiol
Pharmacist : Kelompok 5
Date :

DRUG THERAPY ASSESSMENT WORKSHEET (DTAW)

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


a. Dari tanggal 1-15 april pasien
Are there drug without a 1. A problem exists. diberikan antibiotik Ceftriaxone
medical indication ? sebagai terapi empiris karena pasien
2. More information is needed for MRS dengan mengalami salah satu
a determination. tanda-tanda infeksi yatu leukosit 11,78
Are any medication unidentified (are x 103/uL sehingga untuk menentukan
any unlabeled or are any-prior to 3. No problem exists or an intervention antibiotik yang spesifik dengan
Correlation between
admission clinic visit-unknown) ? is not needed. penyakit pasien masih menunggu hasil
Drug Therapy and
kultur.
Medical Problem
b. Pada tanggal 6,7 April pasien
Are there untreated medical mengalami stress ulcer, Sebaiknya
conditions ? pasien mendapatkan terapi untuk
menangani stress ulcernya. Terapi
Do they require drug therapy ? stress ulcer yang direkomendasikan
adalah Ranitdine 2x50 mg iv.
a. Transfusi PRC diberikan kepada pasien
1. A problem exists. dengan kadar Hb 7-8 g/dl (Murphy et
al, 2001; Carson et al, 2011). Menurut
2. More information is needed for a literatur panduan untuk transfusi pada
determination. perisurgical anemia yang disarankan
adalah dengan kadar Hb 6-8 g/dl
3. No problem exists or an intervention is (Dipiro, 2008). Rekomendasi dari
not needed. AABB guideline : Untuk pasien post-
op disarankan transfusi ketika kadar
Hb ≤ 8g/dl (Medscape). Sedangkan Hb
pasien pada tanggal 1 adalah 9,0 g/dl,
What is the comparative efficacy of tanggal 2 adalah 9,1 g/dl, sehingga
the chosen medication(s) ? pada tanggal 1,2 dan 3 april tidak perlu
diberikan transfusi PRC. Namun
direkomendasikan menggunakan
Appropriate Drug
What is the relative safety of the terapi Fe seperti sulphas ferosus
Selection
chosen medication(s) ? dengan dosis ; 2-4mg/kgBB 2x sehari
jadi dosis untuk pasien adalah 120-240
mg 2x sehari (Guideline for the
Has the therapy been toilered to this management of iron deficiency
individual patient ? anemia, 2005).
b. Pada tanggal 6,7 April pasien
mengalami stress ulcer,
Direkomendasikan pasien
mendapatkan terapi ranitidine.
c. Tanggal 2-3 April 2015, Transfusi
albumin tidak perlu diberikan kepada
pasien yang masih bisa menerima
nutrisi melalui oral, sehingga pasien
perlu diberi nutrisi untuk
meningkatkan kadar albumin seperti
diet TKTP
d. Penggunaan ketolorac dan metamizol
pada tanggal 2,3,5,7,8 April 2015
tidak ada indikasi nyeri. Pasien tidak
merasakan nyeri namun tetap
diberikan analgetik untuk indikasi
nyeri dengan skala sedang sampai
berat. Sehingga sebaiknya ketorolac
dihentikan dan diganti dengan
paracetamol atau metamizole
e. Penggunaan Pil Kutuk ditujukan untuk
peningkatan kadar albumin dan
mempercepat penyembuhan luka
namun belum ada evidence based
medicine yang kuat dan tidak
tercantum dalam Formularium
Nasional ataupun Formularium RS Dr.
Soetomo sehingga sebaiknya pil kutuk
tidak diberikan
a. Antibiotik dalam hal ini Ceftriaxone
Are the prescribed dose and dosing 1. A problem exists.
digunakan untuk pasien yang
frequency appropriate-within the
Drug regimen
usual therapeutic range and/or 2. More information is needed for a menunjukan lebih dari dua tanda-tanda
modified for patient factors ? determination.
SIRS seperti leukositdiatas normal,
Is the route/dosage form/mode of 3. No problem exists or an intervention suhu dibawah 36 atau diatas 38 C, RR
administration appropriate, is not needed.
>20x/menit, HR>90x/menit,
considering efficacy, safety,
convenience, patient limitation, sedangkan pada pasien ini 72 jam
and cost ?
setelah operasi tidak mengalami tanda-
Are doses scheduled to maximize tanda SIRS. Sehingga penggunaan
therapeutic effect and compliance
Ceftriaxon pada tanggal
and to minimize adverse effect, drug
interactions, and regimen complexity 4,5,6,7,11,12,13,14, dan15 April dapat
?
dihentikan (PPAB, 2009). Dan
Is the length or course of therapy direkomendasikan pemberian terapi
appropriate ?
antibiotic topical metronidazole (The
American Journal of Surgery 188
(Suppl to July 2004) 42S–51S)
b. Pada tanggal 1 April, pada saat operasi
pasien tidak diberikan terapi
pencegahan mual dan muntah, namun
hanya diberikan Metoklorpamid
setelah operasi pada tanggal 2 April
sebagai terapi untuk mengurangi atau
mencegah terjadinya post operative
nausea-vomitig.(PONV). Pemberian
Metoklorpamid tidak
direkomendasikan diberikan sebelum
tindakan operasi namun dapat
diberikan setelah tindakan operasi
dengan dosis 25-50 mg secara
intravena dalam waktu 12 jam post-
operasi (Guideline for The
Management of Postoperative Nausea
and Vomiting)
1. A problem exists. Tidak ada duplikasi terapi

2. More information is needed


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

Is the patient allergic to or intolerant 1. A problem exists. Pasien tidak menunjukkan riwayat alergi
of any medicines (or chemically pada penggunaan obatnya
related medications) 2. More information is needed
currently being taken ? for a determination.
Drug allergy
Intolerance
Is the patient using any method to 3. No problem exists or an
alert health care providers of the intervention is not needed.
allergy/intolerance (or serious
medical problem) ?

Are there symptoms or medical 1. A problem exists a. Tidak mengalami efek samping
problems that may be drug induced ? b. Efek samping potensial :
Adverse Drug Events
2. More information is needed for - Ceftriaxone :
What is the likelihood that the a determination. Trombositopenia dan leukopenia (
problem is drug related ? ≥ 10%) (Aronson, 2005)
3. No problem exists or an - Ketorolac : Pusing, dyspepsia,
intervention is not needed. mengantuk, nyeri GI, mual ( ≥
10%) (Aronson, 2005)
- Metoklorpramid : Ekstrapiramidal,
gelisah, lelah ( ≥ 10%) (Aronson,
2005)
a. Tidak terjadi interaksi antara obat-
Are there drug-drug interactions ? 1. A problem exists. obatan yang digunakan pada pasien.
Are they clinically significant ? b. Tidak ada obat-obat yang
Are any medications 2. More information is needed for a kontraindikasi pada kondisi pasien.
contraindicated(relatively or determination.
Interactions :
absolutely) given patient
Drug-drug,
characteristic and 3. No problem exists or an
Drug-Disease
current/pass disease states ? intervention is not needed.
Drug-nutrient, and
Drug-Laboratory Test
Are there drug-nutrient interactions ?
Are they clinically significant ?

Are there drug-laboratory test


interactions ?
Are they clinically significant ?

Is the patient’s current use of social 1. A problem exists.


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

Failure to Receive Pada tanggal 6 dan 7 pasien


Therapy Has the patient failed to receive 1. A problem exists. mengeluhkan mual dan muntah yang
medication due to system error or kemungkinan disebabkan karena stress
noncompliance? 2. More information is needed for a sehingga dapat mengalami stress ulcer,
determination tapi pasien tidak mendapat terapi untuk
Are there factors hindering the penanganan mual dan muntah. Sebaiknya
achievement of therapheutic 3. No problem exists or an intervention pada tanggal 6-7 April pasien diberi
efficacy? is not needed. Ranitidine i.v drip 2x50mg untuk
mengatasi mual muntah karena stress
ulcer (Dipiro, 2009).

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 3. No problem exists or an
patient ? intervention is not needed.

Does the patient understand the 1. A problem exists. Perlu adanya pemberian informasi ke
purpose of his or her medication(s), pasien ataupun keluarga pasien mengenai
how to take it and the potential side 2. More information is needed for a tujuan pengobatan dan bagaimana agar
Patient Knowledge effect of therapy ? determination pengobatan yang dilakukan dapat
of Drug Therapy mencapai hasil yang maksimal
would the patient benefit from 3. No problem exists or an
education intervention is not needed.
tool (e.g., writen patient education
sheets, wallet cards and reminder
packaging) ?

DRUG THERAPY PROBLEM LIST (DTPL)


PATIENT : PHARMACIST :
LOCATION/ROOM :
Date Problem Action/Intervention Date Problem Action/Intervention

PHARMACIST’S CARE PLAN (PCP)


PATIENT : PHARMACIST :
LOCATION/ROOM :
Pharmacotherapeutic Recommendations Monitoring Monitoring
Health Care Need Desired Endpoint(s)
Goal for therapy Parameter(s) Frequency

PHARMACIST’S CARE PLAN MONITORING WORKSHEET (PCPMW)


PATIENT : PHARMACIST:
LOCATION/ROOM :
Date/Time
Pharmacotherapeutic Monitoring
Desired Endpoint(s) Monitoring Frequency
Goal Parameter

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