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OP Data Collection Proforma

The document is a proforma for collecting outpatient case data at Aditya Pharmacy College, detailing patient information, medical history, physical examination, diagnostic test results, and prescribed medications. It includes sections for documenting pharmaceutical care issues, clinical pharmacist interventions, and patient counseling on disease management and medication adherence. The form is intended for use by students and faculty in the Department of Pharmacy Practice to ensure comprehensive patient care.

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22 views4 pages

OP Data Collection Proforma

The document is a proforma for collecting outpatient case data at Aditya Pharmacy College, detailing patient information, medical history, physical examination, diagnostic test results, and prescribed medications. It includes sections for documenting pharmaceutical care issues, clinical pharmacist interventions, and patient counseling on disease management and medication adherence. The form is intended for use by students and faculty in the Department of Pharmacy Practice to ensure comprehensive patient care.

Uploaded by

linia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ADITYA PHARMACY COLLEGE (A)

Affiliated to JNTUK, Accredited by NAAC, and Approved by AICTE, PCI, UGC, and ISO
Aditya Nagar, ADB Road, Surampalem-533437, Andhra Pradesh, India.

DEPARTMENT OF PHARM. D/PHARMACY PRACTICE


OUT-PATIENT CASE DATA COLLECTION PROFORMA

Patient’s Initials: Age & Gender: Occupation:


Address: Height & Weight: OP No.:
Department: Date of Consultation: Consultant:

Reason(s) for Admission


Examination of Vital Signs
(Chief Complaints with the Duration)
Body Temperature:
Heart Rate:
Pulse Rate:
Blood Pressure:
Respiratory Rate:
SPO2:
Any Other Signs:

Past Medical & Medication History

Surgical History Immunization History Family History

Personal/Social History
Level of Education: Marital Status:
Socio-economic Status: Appetite:
Sleep Pattern: Bowel Habits:
Micturition: Smoking:
Alcohol Habit: Drug Abuse:
History of Close Contact with Animals: Physical Activity/Exercise:
Diet: Menstrual History:
Known Allergies: Birth History in the Case of Infants:
Any Others, Specify:

PH YSIC A L EXA MI NATI ON

Pallor Icterus Cyanosis Clubbing Edema

Sensorium: Conscious ( ) Drowsy ( ) Comatose ( ) Any other:


System Remarks on Observation
Respiratory
Cardiovascular
Gastrointestinal & Abdomen
Central Nervous System
Psychiatric
Endocrine
Musculoskeletal
Any others

Laboratory/Diagnostic (Radiology/Serology) Test Results

DIAGNOSIS

PRESCRIBED MEDICATIONS
Name of the Medication For how
Dose ROA Frequency Indication
(Generic Name) many days
PHARMACEUTICAL CARE ISSUES
DRUG INTERACTIONS (IF ANY)

ADVERSE DRUG INTERACTIONS (IF ANY)

RATIONALITY OF THE PRESCRIPTION

CONDITION SPECIFIC PATHOPHYSIOLOGY

CLINICAL PHARMACIST INTERVENTIONS (IF ANY)


PATIENT COUNSELING REGARDING THE DISEASE
(C au se s, S ig ns & Sy mp to ms , R isk F ac t o r s, and Co mp li c at io ns)

PATIENT COUNSELING REGARDING THE MEDICATIONS


(B r ie f ab o ut t h e Dir e ct i o ns f or use , P o ss ib le F o o d -Dr ug I nt er ac t io ns, S i de E f fe c t s, an d M e dic a t io n
A dh er e nc e)

PATIENT COUNSELING REGARDING THE LIFESTYLE


MODIFICATIONS

Collected by: Regd. No.:

Year of Study: Date of Collection:

Remarks Signature of the Faculty/Preceptor with date

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