Data

Service Type:

Original Prescription

Medication name:

Dose:

Frequency:

History of use:

Indication:

Objective Data

BP reading:

/

mmHg , Source

K+:

mmol/L, Date

eGFR:

mL/min, Date

A1C:

, Date:

SMBG:

Hypoglycemia:

eGFR:

mL/min, Date

LDL:

, Date:

HDL:

, Date:

TG:

, Date:

Chol:

, Date:

GAD-7:

PHQ-9:

Rescue inhaler use: times per week.

Subjective Data

Side Effects:

No side effects

Other comments:

Assessment

Medication is:

Indicated?

yes

no:

Safe?

yes

no:

Effective?

yes

no:

Adherence:

Patient is adherent based on:

pharmacy records

Netcare

patient conversation

Patient is not adherent due to:

Other comments:

Plan

Adapted Prescription

Medication name:

Dose:

Frequency:

Extension quantity:

Follow-up

Pharmacist with patient

Patient with doctor:

Refills

Further assessment

Other comments:

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