CONTOH FORMAT SOAP

PHARMACEUTICAL CARE

PATIENT PROFILE

Tn. / Ny.

Jenis Kelamin : Tgl. MRS :

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

Presenting Complaint

Diagnosa kerja : (misal suspect DHF)

Diagnosa banding : (misal typhoid, malaria)

 Relevant Past Medical History:

Drug Allergies:

Tanda-tanda Vital tgl tgl tgl tgl tgl tgl

Tekanan darah
Nadi
Suhu
RR
Medication
No Nama Obat Indikasi Dosis yang Dosis Terapi
. digunakan (literatur)
1
2
3
4
Laboratory Test
Test (normal range) tgl tgl
WBC (4000-10000/mm3)
Hb (L: 13-17 g/dL)
RBC (4-6x106/mm3)
Hct (L:40-54%)
MCV
MCH
MCHC
PLT (150000-450000/mm3)
MPV
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)
Chlorida (95-103 mEq/L)

Significance of results Arti Kemungkinan penyebab

outside normal range
WBC (misal) Tanda Kemungkinan infeksi, ADR …
infeksi
Hb ¯, Hct ¯ (misal) Tanda Kemungkinan anemia, DHF,
anemia / ADR …
trombositop
enia
LED  (misal) Tanda Terdapat reaksi inflamasi akibat
inflamasi aktivitas system imun / infeksi
Natrium¯ (misal) Hiponatremi Kemungkinan karena pasien
a muntah, gangguan
keseimbangan elektrolit

Further Information Required Alasan

1.
2.
3.

Problem List (Actual Problem)

Medical Pharmaceutical
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 SOAP 1

PHARMACEUTICAL PROBLEM Manajemen ....

Subjective (symptom)

- Objective (signs)

-
Analysis (with evidence)

Plan (including primary care implications)

DAFTAR PUSTAKA
(umumnya dituliskan dengan metode Vancouver)