PHARMACEUTICAL CARE PLAN

(To be made and filled by a Pharmacist. Take interview for proper planning.)

Patient Profile Patient Pic

Full name:

Nationality: Religion:

Date of birth (dd/mm/yyyy): / /

Age (years/month): Thumb Impression

Gender

o Female o Male
Race Signature
o Black o White
Allergy

o Medication o Food o Pollen o Dust

Please specify

Medication:

Food:

Identity number/Passport number:

Address:

Contact number (also put international code):

Contact E-mail:

Occupation:

Social Life

o Higher Class o Middle Class o Lower Class

Weight: kg Height: ft

Biomass Index (BMI):

o Overweight o Normal Weight o Underweight

Complains:

o Vertigo o Dry mouth o Sneezing o Pain

o Abdominal o Rashes o Shortness of o Headache
pain o Chest pain Breath o Backache
o Inflammation o Diarrhea o Itchy eyes o Pain in teeth
o Constipation o Running nose o Blurred
o Urinary Tract o Nasal vision
Inflammation congestion o Coughing

If other (including case of emergency), specify complains:

History of Past Illness:

History of past medication used

Brand API Dosage Form Route Dose Frequency Duration

Current situation description about illness including history:

.
Personal Habbits

o Smoking
o Narcotics addiction
o Sports
o Alcohol use

Please specify extent of habbits and any other if patient has:

Vaccination/Immunization:

o Chickenpox
o Diphtheria
o Whooping cough
o Hepatitis A
o Hepatitis B
o Influenza
o Measles, Mumps, Rubella (MMR)
o Meningococcal
o Pneumococcal
o Polio
o Rotavirus

Write details about vaccination / Immunization:

Any further details, write down

 CORE PHARMACOTHERAPY PLAN
Condition of Patient

Consulting Physician/Surgeon:

Hospital/Clinic:

Blood reports:

Urine analysis reports:

Liver Function Test reports:

Renal Function Test reports:

Electrolyte test reports:

Physical Examination:

o Pulse rate ( bpm) o Temperature ( º )

o Respiratory rate ( breaths per minutes) o Blood Pressure ( / )
Radiography reports (X-ray, MRI, CT scan):

ECG:

Ultrasonography:

Culture Test:

ECHO test:

Final Diagnosis
Outcome desired

Outcomes desired:

Patient must be told about the condition and then outcome desired to achieve therapeutic success. If patient
is not told, what is the reason? Specify

For further details, write

Regimen Selection

Drug Dosage Route of Dose Frequency Schedule/Duration Brand

Form Administration

Non-pharmacological treatment recommendation

If giving other type of treatment like radiation, surgical intervention, write in detail
Evaluation

Progress monitoring tests recommendation

o ECHO test o Electrolytes test o LFT

o Physical Examination o Radiography o RFT
o Sonography o Blood Test
o ECG o Urine analysis

Specify details of tests

Any further recommendation, write here

 PRIME PHARMACOTHERAPY PROBLEMS
Pharmaceutical based Problems

Checklist (Tick mark when done)

o Is dose of each drug is correct?

o Is the dosage form and route of administration correct?
o Does the dosage form and route of administration enhance patient compliance?
o Is the selected brand appropriate in comparison to other brands?

Any further detail, write here

Risks

Possible ADRs

o Hallucination
o Depression
o Vertigo
o Dry cough
o Cycloplegia
o Bleeding difficult to stop
o Haematological toxicity
o Arrhythmia

If any other ADR, mention here

ADR Prevention

Drug Dosage Route of Dose Frequency Duration ADR Resolution

Form administration
Interactions

Drug – Drug/Supplement/Herbal interaction

Drug Interacting Way of interaction Effective/Dangerous Resolution

Drug/Supplement/Herbal (Enzymatic,
Pharmacodynamic,
Pharmacokinetic)

(if drug is to be omitted due to interaction, cut the drug from CORE and write another suitable one in the CORE. Write name of
drug in resolution.)

Drug – Food Interaction

Drug Type of food Way of interaction Effective/Dangerous Resolution

interacting
Water
Protein food
Fatty food
Carbohydrates

For further details, write here

Mismatch

(Write the drugs and interaction that are present in patient. Then match, if not suitable, change Regimen)

Drug Dosage Route of Dose Frequency Duration Indication Correct Resolution

Form administration /Incorrect

Further details
Efficacy Issues

Checklist (Tick mark when checked or done)

o Have the efficacy issues occurring due to drug interaction been solved?

o Has it been checked that recommended regimen will be not toxic?

o Has the dose been checked or calculated against BMI, age, and other situtations?

o Is the dosing frequency correct?

o Has the duration specified and correct to achieve therapeutic success?

o Has patient been counseled about all this so to make regimen efficacious and hence the

pharmacotherapy plan successful?

 SOAP / FARM note
Use only any one of the following. Tick mark above which is being used

Subjective/Findings

Objective/Assessment

Assessment/Resolution

Plan/Monitoring

Clinical Pharmacist

Signature

Registration Number