Activity On Hospital Documentation

HOSPITAL PHARMACY
Name: 3 Ph Date Submitted:
Activity on Hospital Documentation
Objectives:
1. Characterize the roles of hospital and clinical pharmacist in medication use management
and medication safety
2. Identify medication use- and distribution- related problems in health care settings
3. Demonstrate the daily activity of drug dispensing and distribution through appropriate
documentation and workflow
Procedures:
1. This is an individual activity.
2. A case scenario will be provided.
3. Answer the following questions and give the BEST answer.
Case Scenario #1:
On August 12, 2020 at around 8:00 in the evening, Patient AM with a registered hospital number of
1234567, a 19-year old Filipino male student residing at Sta. Cruz Manila, was brought to the emergency
room due to right arm injury caused by playing basketball. Four hours prior to consult, the patient slid
and landed on his right elbow and a deformity was evident. The patient complaint of severe pain with a
VAS of 7/10 rating, 10 being the highest. Upon admission, at 9:15 in the evening, he was given Celecoxib
200mg tablet for initial pain relief. The medical resident-on-duty, Dr. Hao, conducted physical
examination on SHEENT (skin, head, eyes, ears, nose and throat), neck, respiratory, cardiovascular,
gastro/abdomen, genitourinary as well as neurological and noted that everything is normal. Complete
blood count was ordered and the result had shown an increased number of white blood cell (11.03)
which is beyond the normal range indicating that there is an infection. There is no history of previous
surgical procedures and there are no known allergies. The patient is a known Diabetic Type II and
currently on Metformin 500mg tablet twice a day, Insulin 70/30 20 units subcutaneous once a day (pre-
breakfast) and Insulin 70/30 40 units subcutaneous once a day (pre-dinner) and these medications were
ordered to be continued on August 13, 2020. Due to the presence of a dislocated right arm, the
physician ordered a radiological examination and the result confirmed the initial assessment. Based on
the physician’s assessment, the admitting diagnosis is dislocated fractured right arm and the patient was
scheduled to undergo surgery but due to unavailability of operating rooms and lack of manpower to
conduct the operation, the dislocated right arm was casted to immobilize the injured part and the
patient was prescribed to take Celecoxib 200mg tablet twice a day to relieve the pain, Mupirocin
ointment 2% to be applied thinly on the affected area with abrasions three times daily for ten days,
Cefuroxime 750mg intravenous every 8 hours to be completed for one week and was on 0.9% Sodium
Chloride 1 liter to run for 12 hours. After referral from the endocrinologist last August 20, 2020, the
medications were revised into Metformin 500mg tablet once a day, Insulin 70/30 10 units subcutaneous
once a day (pre-breakfast) and Insulin 70/30 20 units subcutaneous once a day (pre-dinner). The patient
was instructed to perform an arm exercise two times a week for one month.
Below is the treatment record utilized by the nurses-on-duty to record the time of medication
administration.
1. Given the scenario, fill-in the Patient Medication Profile. Please write N/A for unfilled details.
PATIENT MEDICATION PROFILE

Patient’s Name: Ward: Hospital Date Admitted:
Social Status: Number: Date Discharged:
Date of Birth: Age: Wt: Ht: Gender:
Diagnosis:
Allergies: Diet: Attending Physician:
DATE OF
DATE/TIME STANDING MEDICATIONS
REMARKS
ORDER
SD ED NAME OF MEDICATION STRENGTH ROUTE FREQ INDICATION
AS NEEDED (PRN) MEDICATIONS
IV FLUIDS STAT MEDICATIONS

DATE OF DESCRIPTION INFUSION REMARKS DATE OF NAME OF MEDICATION STRENGTH ROUTE
ORDER RATE ORDER
TREATMENT
DATE OF DATE/TIME
ORDER SD ED NAME OF MEDICATION STRENGTH ROUTE FREQ INDICATION REMARKS
Case Scenario #2:
Upon chart reading of CP Louise Arriola (Clinical Pharmacist) last August 21, 2020 at 6:30 in the morning,
she found out that the revision made by the endocrinologist last August 20, 2020 was not followed by
the nurses. The previous medication order for Metformin and Insulin 70/30 were still transcribed and
administered to the patient.
2. Given the scenario, fill-in the Clinical Pharmacist’s Intervention Form. Please write N/A for unfilled
details.
CLINICAL PHARMACIS’TS INTERVENTION FORM (PDAR)

Patient’s Name: Ward: Hospital Number: Date:
Social Status: Time:
Date of Birth: Age: Wt: Ht: Gender:
Diagnosis:
Allergies: Diet: Attending Physician:
Problem/s Identified:
Medication/s:
Assessment (Clinical Pharmacist):
Reference/s:
Clinical Pharmacist’s Printed Name & Signature / Date

Response: I accept
I do not accept
Printed Name & Signature / Date

Activity On Hospital Documentation - HospPharmLab Act 1

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HOSPITAL PHARMACY

Name: 3 Ph Date Submitted:

Case Scenario #1:

PATIENT MEDICATION PROFILE

AS NEEDED (PRN) MEDICATIONS

IV FLUIDS STAT MEDICATIONS

CLINICAL PHARMACIS’TS INTERVENTION FORM (PDAR)

Assessment (Clinical Pharmacist):

Clinical Pharmacist’s Printed Name & Signature / Date

Printed Name & Signature / Date

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