HOSPITAL UNIVERSITRIO PROF.

EDGARD SANTOS
SERVIO DE FARMCIA
FICHA DE SEGUIMENTO FARMACUTICO
Aluno ________________________________________________________ Semestre____________________________

Nome:__________________________________________________

Reg.:_____________

Unidade/leito:________/________

Mdico responsvel:

Admisso:____/____/____

Data: ____/_____/____

____________________________CRM________

bito: No Sim

Alta: _____/_____/_____

Farmacutico responsvel:
____________________________CRF________

Data : _____/_____/_____

Endereo:_________________________________________________________________ Tel.: (

) ______________

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Data de nasc.: _____/_____/_____

Peso:_______Kg

Altura:________cm

IMC:__________________

Sexo:

Raa:

Masculino Feminino

Branca Negra Mulata Amarela Outra:_______________________________

Religio:
Catlica

Protestante

Outra:_______________________

Profisso:__________________________________

Escolaridade: Analfabeto 1 grau incompleto 1 grau completo 2 grau incompleto 2 grau completo
Superior incompleto Superior completo Ps-graduao

H aumento do risco de reaes adversas devido a idade, sexo ou raa?

No Sim. Especificar:_______________________________________________________________
O metabolismo e eliminao de algum medicamento podem ser afetados pela idade, sexo ou raa?
No Sim. Especificar:_______________________________________________________________
O peso do paciente afeta o clculo das doses?
No Sim. Especificar:_______________________________________________________________
Lista de problemas mdicos/diagnstico:
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Histria mdica passada e atual:

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Tratamento atual:
Medicamento

Dose

Via

Freqncia

Incio

Trmino

Parmetros de
monitorao

Algum medicamento pode alterar a funo renal?

No Sim. Especificar:______________________
A funo renal pode afetar a eliminao de algum medicamento?
No Sim. Especificar:______________________
Que informao necessria para assegurar que a terapia recomendada est produzindo o efeito
teraputico desejado?_________________________________________________________________
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Qual a freqncia e tempo necessrio para a coleta das informaes relevantes?________________
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Histrico de uso de medicamentos:
Medicamento

Dose

Via

Freqncia

Incio

Trmino

Aderncia:
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Alergias:
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Tabagismo:
No Sim. Freqncia:______________________
Etilismo:
No Sim. Freqncia:______________________
Uso de drogas ilcitas:
No Sim. Especificar:____________________
Prtica de atividade fsica:
No Sim. Especificar:____________________
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Sinais Vitais:
Data

Temperatura (C)

FC (bpm)

PA (mmHg)

FR (ipm)

Quais valores laboratoriais de referncia so necessrios na antecipao da efetividade teraputica e o

monitoramento da toxicidade dos medicamentos?
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Quais exames so necessrios para determinar a efetividade da terapia atual?
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Quais exames so necessrios para determinar se a terapia atual est causando toxicidade?
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Valores laboratoriais pertinentes:
Exame

Valor de

Datas

referncia

Problema relacionado ao

Classificao

Resultado teraputico

Alternativa

desejado

teraputica

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medicamento

Interveno

Quais problemas voc vai resolver para esse paciente?

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Quais problemas voc vai assumir a responsabilidade como farmacutico?
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Houve impacto econmico nas intervenes realizadas?
No Sim. Especificar:__________________________________________________________________________
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Data

Necessidades relacionadas com o medicamento, preocupaes, perguntas, expectativas

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Notas de Evoluo (avaliao do seguimento):

Data

Evoluo
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Recomendaes na alta hospitalar (medicamentos / terapia no farmacolgica):

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Cdigos de problemas relacionados ao uso de medicamentos:

Cdigo

Tipo

Causa
No se conhece nenhuma neste momento

1A

Indicao

1B

Necessita tratamento Tratamento sinrgico

1C

Transtorno no tratado

Tratamento profiltico

2A

Indicao

Ausncia de indicao

2B

Tratamento

Adio/consumo de drogas de abuso

2C

farmacolgico

2D

necessrio

2E

no Tratamento no farmacolgico apropriado

Tratamento duplicado
Tratamento de RAM evitvel

3A

Efetividade

Forma de administrao inadequada

3B

Medicamento

Presena de contraindicao

3C

inadequado

Transtorno resistente ao medicamento

3D

Medicamento no indicado ao transtorno

3E

Existncia de um medicamento mais efetivo

4A

Efetividade

Dose inadequada

4B

Subdose

Freqncia inadequada

4C

Durao inadequada

4D

Armazenamento incorreto

4E

Administrao incorreta

4F

Interao medicamentosa

5A

Segurana

Medicamento perigoso para o paciente

5B

Reao adversa ao Reao alrgica

5C

medicamento

Administrao incorreta

5D

(RAM)

Interao medicamentosa

5E

Aumento/diminuio de dose demasiadamente rpido

5F

Efeito indesejvel

6A

Segurana

Dose inadequada

6B

Sobredose

Freqncia inadequada

6C

Durao inadequada

6D

Interao medicamentosa

7A

Aderncia

Medicamento no disponvel

7B

Recursos no suficientes para adquirir o medicamento

7C

Impossibilidade de deglutio/administratao

7D

Falta de compreenso

7E

Os pacientes preferem no tomar o medicamento

Adaptado de El Ejercicio de la Atencion Farmaceutica, Cipolle et al, 1ed. 2000, Madrid, Espanha.