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Borang CP3

This clinical pharmacy report form summarizes a pharmacist's ward rounds and patient encounters. Section A describes the ward pharmacy activity including the ward visited, number of patient cases reviewed, and medication histories taken. Section B lists the types of interventions encountered, including incomplete prescriptions, inappropriate regimens, and miscellaneous issues. It records the number of each type of intervention and those accepted. Section C provides space to describe specific requests or interventions. Section D is for documenting any required follow-up. The form is used to record the pharmacist's contributions and recommendations for patient care.

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1K views2 pages

Borang CP3

This clinical pharmacy report form summarizes a pharmacist's ward rounds and patient encounters. Section A describes the ward pharmacy activity including the ward visited, number of patient cases reviewed, and medication histories taken. Section B lists the types of interventions encountered, including incomplete prescriptions, inappropriate regimens, and miscellaneous issues. It records the number of each type of intervention and those accepted. Section C provides space to describe specific requests or interventions. Section D is for documenting any required follow-up. The form is used to record the pharmacist's contributions and recommendations for patient care.

Uploaded by

farmasi.ketengahjaya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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HSAJB/FAR-63/VER1.

0/2019 CP3
CLINICAL PHARMACY REPORT FORM

Pharmacy Department, Hospital Sultanah Aminah Johor Bahru


A: WARD PHARMACY ACTIVITY
Date : Routine Rounds
Ward : Grand Rounds
Task : Full Time / Part Time Pharmacist Rounds
Physician(s) : Number of Cases Clerked
Number of Cases Reviewed
Number of Patients in Ward
Number of Medication History (CP1) Taken

B: INTERVENTIONS / REQUESTS ENCOUNTERED

Number of
Number of Request / Information
Interventions No. Description Interventions Number Total
Interventions Provided
Accepted
1.1 Patient data Adverse Drug Reaction

1.2 Drug Drug Toxicity


(1) 1.3 Dose Drug Dosage
Incomplete
Prescription 1.4 Frequency Therapeutic Efficacy

1.5 Duration Drug Indication

1.6 Dr’s Stamp & Sign Drug Interaction

2.1 Drug Pharmacokinetics


2.2 Dose TPN
2.3 Frequency General Product Information
(2) 2.4 Duration Pharmaceutical Availability
Inappropriate
Regimen 2.5 Polypharmacy Pharmaceutical Compatibility
2.6 Contraindication Pharmaceutical Identification
2.7 Drug Interaction
2.8 Incompatibility

3.1 Wrong Patient

3.2 Drug Not in Formulary


Drug Administration
3.3 TOTAL INFORMATION PROVIDED
Error
3.4 Unclear Handwriting
(3) Authenticity of
Miscellaneous 3.5 Prescription/ Total
Prescriber Number
Number
COUNSELLING of
Suggest For Vital of
Sessions
Signs Monitoring/ Patients
3.6
Laboratory
Investigation Bedside Counselling

3.7 TDM Discharge Counselling

3.8 TPN Group Counselling

TOTAL INTERVENTIONS GRAND TOTAL

C: DESCRIPTION OF REQUESTS / INTERVENTIONS ENCOUNTERED


HSAJB/FAR-63/VER1.0/2019

D: FOLLOW-UP REQUIRED
NO. FOLLOW-UP CHECKLIST SIGN

…………………………..
Pharmacist’s Sign & Stamp
Date:
Pin. 1/13

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