PATIENT JOURENY

ADMESSION

IN PATIENT

DISCHARGE

ADMESSION :
An accurate medicine history is obtained by
ACPT (accredited check pharmacy technicion)
or junior pharmacist by printing ECR of the
patient
Medicine history should contain the following
-Current ,recently prescribed medicines
-OTC ,clinical trials,unlicinced drugs,
-Herbal remedies,recreational drugs
-Smoke and alchol consumptions
-Recent vaccination
-Any previouse adverse effects and known
allergies

Patient then is categorized in priority as red , yellow

or green according to his medication
Patient is selected for reconciliation according to
priority
Pharmacist prepare himself for the interview with
patient after reading his ECR and kardex
Patient interview and collecting data from at least
two sources as ex:ECR,GP, kardex or POD
Medicine reconciliation (MedRec) by comparing
patient ECR and kardex and documenting any
discripancies,deletion,addition and changes to obtain
an up to date list of drugs .

IN PATIENT (PHARMACEUTICAL
CARE PLAN )

After collecting data and medicine reconciliation :

Identify any issues
Pritortising issues
Identify theraputic goal for each priority issue,
goal should be specific,relevant to the patient and
target outcomes including refrence ranges and
units
Taking actions you would take to achieve
therapeutic goals
Grade the intervention by Edwen scale
All SOPs should be covered by using check list

DISCHARGE :
Prior discharge pharmacist review current pcp and anticipates
any pharmaceutical care issues
Pharmacist ensures that all medicines prescribed at discharge
are clinically accurate and appropriate
Pharmacist check written or electronic information to primary
care health care detailing :
-current medication
-change to medicine and reason for change
-information needed to continue supply of medicine in primary care
-monitoring requirment ex:warfarin
Pharmacist ensures that the patient is dispensed an appropriate
quantity of medicines
Pharmacist ensures that the patient is educated on prescribed
medicines as appropriate and his adherence to the treatment

M.H. Male patient has 54 years old admitted to the

hospital suffering from vomitting, dyspnea ,productive
cough .He was diagnosed to have gastritis and COPD
Drugs prescribed on admission :
Rantidine 150mg IV every 8 hours
Metoclopramide IV every 8 hours
Pantoprazole 40 mg IV every 24 hours
Vitamine B 12 IM every 24 hours
Triambutate 200 every 8 hours
Budesonide 400mg every 6 hours
Formetrol fumarate 12microgram every 12 hours
Acetylcystine 200 mg every 12 hours
Gentamycine 80 mg IV every 12 hours for 5 days
Sulbactam /ampicillin 1.5 every 8 hours
Saline and Ringer every 8 hours

Patient details/ addressograph

Name : M. H.
Age : 54 years

green

Allergies/medicines senseitivites
This section must be completed
Date

Medicine(generic)/
Allergen

Type of reaction

Signature

or
No known drug allergies
Signature: Ghada Hussein

date :7/9/2015

Admission history taken by :

Name : Ghada Hussein Ahmed
Designation :Pharmacist
Date : 6/9/2015
Bleep number :---------------Indicate information sources used (tick)
GP

patient

Community pharmacy

Nursing home kardex

Previouse discharge

relative

Patients own drugs

Other (please state)

patient
kardex

MEDICATIONS

Medication review
STOP
PED

held

Dose
altered

comments

NAME

DO
SE

Freq
uenc
y

CONTI
NUED

Not yet
reconciled

Rantidine

150
mg

Q
8hrs

Continue as prescribed

metoclopra
mide

10
mg

Q
8hrs

Continue as prescribed

pantopraz
ole

40
mg

Q
24hr
s

Stop it due to duplication

with rantidine

Vitamine
b12

1
mg

Q
24hr
s

Continue as prescribed

trimebutin
e

200
mg

q8hr
s

Continue as prescribed

budesnoide

400
mg

Q6
hrs

Dose should be altered to be

once daily

Formetrol
fumerate

12
g

Q 12
hrs

continued as prescribed

ACC

200

Q12
hrs

Continued as prescribd

gentamycin

80

stop it as guidelines not

drug

dose

frequency

sulbacta
m/ampicil
lin

1.5mg

Q 8 hrs

Continued as
prescribed

saline

500
ml

Q 8 hrs

Continued as
prescribed

ringer

500
ml

Q 8 hrs

Continued as
prescribed

Medication review

comments

Herbal/over the counter medicines : NO

Recent vaccination history: NO

Own medication in hospital reviewed by :

Ghada hussein ahmed

Compliance issues : yes

Clinical pharmacists recommendation on admenstration:

Stop pantoprazole and continue on rantidine as prescribed ,stop gentamycin
as guidelines of COPD dont recommend for it and dose of budesnoide should
be altered to be once daily other drugs should be continued as prescribed