PATIENT FOLLOW UP RECORD
Demographic
Patient Name Ward [Link] Sex Age Weight Height BMI DOA DOD
---Drug Therapy Problems Identified/ ---No drug therapy problem were identified
Priority Number Drug Therapy Problem(DTP)
Assessment: ---Follow/Up ---Follow/Up Resolved
Status of DTP
--Resolved –Stable --Improved –Partial improvement
(Or Medical problem for rou-
--Unimproved --Worsened --Failure --Expired
tine follow-up)
Individuals contacted for Fol-
low Up --Patient –Others --Physician in Writing -- Physician by phone
Pharmacy Care Plane --Continue with previous therapeutic plan --Develop Therapeutic plan based on previous
--outcomes
Therapeutic Plan/Endpoints
Monitoring Plan --Continue with previous plan --New monitoring plan
Follow-Up Note
Signature &Name of the student Signature of Preceptor with Date
DRUG THERAPY PROBLEMS
UNNECESSARY DRUG THEAPY NEEDS DIFFERENT DRUG PRODUCT
No Medical Indication
More Effective Drug Available
Duplicate Therapy
Condition Refractory to Drug
EFFECTIVENESS
Non-Drug Therapy Indicated
INDICATION
Dosage from Inappropriate
Treating Avoidable ADR
Not Effective for Condition
Addictive / Recreational
NEEDS ADDITIONAL DRUG THERAPY DOSAGE TOO LOW
Wrong Dose
Untreated Condition
Frequency Inappropriate
Preventive/Prophylactic
Drug Interaction
Synergistic/Potentiating
Duration Inappropriate
ADVERSE DRUG REACTION NON-COMPLIANCE
Undesirable Effect
Unsafe Drug for Patient
Drug Interaction
Dosage Administered or
COMPLIANCE
Changed Too Rapidly Directions Not Understood
Patient Prefers Not to Take
SAFETY
Allergic Reaction
Contraindications Present Patient Forgets to Take
DOSAGE TOO HIGH Patient Cannot Afford
Cannot Swallow/Administer
Wrong Dosage
Drug Product Not Available
Frequency Inappropriate
Duration Inappropriate
Drug Interaction
Incorrect Administration
PATIENT STATUS CATEGORY
STATUS DEFINITIONS
Resolved Therapeutic goals achieved for the acute condition, discontinue therapy
Therapeutic goals achieved, continue the same therapy for chronic disease
Stable
management
Progress is being made in achieving goals, continue the same therapy be-
Improved
cause more time is required to assess the full benefit of therapy
Progress is being made, but minor adjustments in therapy are required to
Partial improvement
fully achieve the therapeutic goals before the next assessment
Little or no progress has been made, but continue the same therapy to allow
Unimproved
additional time for benefit to be observed
A decline in health is observed despite an adequate duration using the opti-
Worsened mal medication; modify medicine therapy (e.g., increase the dose of the cur-
rent medication, add a second agent with additive or synergistic effects)
Therapeutic goals have not been achieved despite an adequate dose and du-
Failure
ration of therapy; discontinue current medication(s) and start new therapy
The patient died while receiving medicine therapy; document possible con-
Expired
tributing factors, if they may be medicine-related
