THE PATIENT CHART

By: Cherrie D. Gasendo, RPh., MS Pharm

THE PATIENT’S MEDICAL RECORD IS A WRITTEN DOCUMENT CONTAINING:

Medical history Findings from physical examination Reports of laboratory tests Findings and conclusions from special

examinations Findings and diagnosis of consultants Notes on treatment including medications,

surgical, operation radiation, physical therapy

Progress notes of physician, nurses and etc

PURPOSE

Serve as important clues with which to begin with making a diagnosis

Present prominent list that serves to remind the physician that these sysmptoms brought him for treatment

BE FAMILIAR OF THE FOLLOWING:

Medical terminologies, prefixes and suffixes Medical abbreviations

PATIENT DRUG PROFILE

PDP OF DDH

Medication orders are entered in the drug profile depending on the order of the doctor

For standing medications the following should be observed: Standing medicine order is entered as is on the

left side of the profile filling up all the necessary information called for.

The name of the medication with the strength is entered in the drug description, and its dosage and frequency and time, route of administration and date ordered are written in their respective columns.

For discontinued medications, the abbreviation D/C in red ink is written beside the item with a red ink crossing out the drug.

For orders where a medication is to be changed to another type of medicine under the same drug classification the word CHANGED is written beside the item with the date crossing out the drug. All these are written in BLACK ink.

The new order is entered in the profile just like a new order.

For medicines that had been reduced or increased the word order for is written beside the item with the date and a BLUE ink crossing out the drug. Enter the new order on another line just like a new order.

Medicines that are deferred are considered as discontinued medicine and follows same procedure for a discontinued medicine.

Abbreviations are used for the route of administration of medicines.

PRN medications are entered in the profile with the dte at the far end of the column.

Single and Stat medication orders are written at the column provided.

Doses of medicines to be given for 2 to 3 doses maybe written at the single order portion of the profile.

EXAMPLE

10/01/07 8am – Admit patient

- Full hypoallergenic diet- CBC, blood typing & urinalysis- Stool exam for parasites and ova- Domperidone (Motilium) 10mg 1 tab TID p.o.- paracetamol 500mg 1 tab q4 for temp. 38 deg. Celsius above- Cefuroxime (Zegen) 500 mg 1 tab BID

10/01/07 10 am- Nexium 40mg 1 tab now then OD- Iselpin 1g ½ tab 1hr a.c.

10/01/07 5pm- Liquid diet- D/C Motilium- Change Nexium to Pantoloc 40mg 1 tab OD- Start ponstan 1 tab q8 PRN for pain

PHARMACIST’S NOTES

MEDICATION ERROR TRACKING FORM

THANK YOU & GOD BLESS!!!