1.

FORM SOAP
PHARMACEUTICAL CARE

PATIENT PROFILE

Tn. / Ny.

Jenis Kelamin : Tgl. MRS :

Usia : Tgl. KRS :
Tinggi badan :
Berat badan :

Presenting Complaint

Diagnosa kerja :
Diagnosa banding :

 Relevant Past Medical History:

Drug Allergies:

Tanda-tanda
tgl tgl tgl tgl tgl tgl
Vital
Tekanan darah
Nadi
Suhu
RR
 LABORATORY TEST
Test (normal range) Tgl tgl
WBC (4000-10000/mm ) 3

Hb (L: 13-17 g/dL)

RBC (4-6x106/mm3)
Hct (L:40-54%)
PLT (150000-450000/mm3)
Gula darah puasa (76-110 mg/dL)
Gula darah 2 jam PP (90-130 mg/dL)
Cholesterol (150-250 mg/dL)
TG (50-200 mg/dl)
Uric acid (L:3,4-7 mg/dL)
Albumin (3,5-5,0 g/dL)
SGOT (0-35 u/L)
SGPT (0-37 u/L)
BUN (10-24 mg/dL)
Kreatinin (0,5-1,5 mg/dl)
Natrium (135-15 mEq/L)
Kalium (3,5-5,0 mEq/L)

N Further Information
Alasan
o Required
1.
2.
3.

Problem List (Actual Problem)

Medical Pharmaceutical
1 1
2 2
3 3
4 4
5 5

PHARMACEUTICAL PROBLEM

Subjective (symptom)
 - Objective (signs)

Assesment (with evidence)

Plan (including primary care implications)

Monitoring
 Efektivitas

 Efek Samping Obat

DAFTAR PUSTAKA
2. Form Medication Record

Nama Pasien Tanggal Waktu Nama Obat Dosis Obat Alergi Obat dan Tanda
Diberikan Obat Pemberian Obat Reaksi Alergi Tangan
Apoteker
 3. Form Medication Reminder

Nama Pasien : Dokter Pemeriksa :

Umur : Apoteker :

Bulan / Tahun
Nama
Waktu (Tanggal Pemberian Obat)
Obat
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Pagi

Siang

Sore

Malam

Pagi

Siang

Sore

Malam