Download - Ficha de Seguimento at FARM
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HOSPITAL UNIVERSITÁRIO PROF. EDGARD SANTOS
SERVIÇO DE FARMÁCIA FICHA DE SEGUIMENTO FARMACÊUTICO
Nome:__________________________________________________
Reg.:_____________
Data: ____/_____/____
Unidade/leito:________/________
Admissão:____/____/____
Médico responsável:
____________________________CRM________
Óbito: Não Sim
Data : _____/_____/_____
Alta: _____/_____/_____
Farmacêutico responsável:
____________________________CRF________
Endereço:_________________________________________________________________
_________________________________________________________________________
Tel.: ( ) ______________
Data de nasc.: _____/_____/_____
Peso:_______Kg
Altura:________cm
IMC:__________________
Sexo:
Masculino Feminino
Raça:
Branca Negra Mulata Amarela Outra:_______________________________
Religião:
Católica Protestante Outra:_______________________
Profissão:__________________________________
Escolaridade: Analfabeto 1º grau incompleto 1º grau completo 2º grau incompleto 2º grau completo
Superior incompleto Superior completo Pós-graduação
Há aumento do risco de reações adversas devido a idade, sexo ou raça?
Não Sim. Especificar:_______________________________________________________________
O metabolismo e eliminação de algum medicamento podem ser afetados pela idade, sexo ou raça?
Não Sim. Especificar:_______________________________________________________________
O peso do paciente afeta o cálculo das doses?
Não Sim. Especificar:_______________________________________________________________
Lista de problemas médicos/diagnóstico:
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Aluno ________________________________________________________ Semestre____________________________
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História médica passada e atual:
Tratamento atual:
Medicamento Dose Via Freqüência Início Término Parâmetros de
monitoração
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Algum medicamento pode alterar a função renal?
Não Sim. Especificar:______________________
A função renal pode afetar a eliminação de algum medicamento?
Não Sim. Especificar:______________________
Que informação é necessária para assegurar que a terapia recomendada está produzindo o efeito
terapêutico desejado?_________________________________________________________________ _______________________________________________________________________________________________________________
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Qual a freqüência e tempo necessário para a coleta das informações relevantes?________________
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Histórico de uso de medicamentos:
Medicamento Dose Via Freqüência Início Término
Aderência:
Alergias:
Tabagismo:
Não Sim. Freqüência:______________________
Etilismo:
Não Sim. Freqüência:______________________
Uso de drogas ilícitas:
Não Sim. Especificar:____________________
Prática de atividade física:
Não Sim. Especificar:____________________
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Sinais Vitais:
Data Temperatura (°C) FC (bpm) PA (mmHg) FR (ipm)
Quais valores laboratoriais de referência são necessários na antecipação da efetividade terapêutica e o
monitoramento da toxicidade dos medicamentos?
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Quais exames são necessários para determinar a efetividade da terapia atual?
____________________________________________________________________________________
Quais exames são necessários para determinar se a terapia atual está causando toxicidade?
____________________________________________________________________________________
Valores laboratoriais pertinentes:
Datas Exame Valor de
referência
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Problema relacionado ao
medicamento
Classificação
Resultado terapêutico
desejado
Alternativa
terapêutica
Intervenção
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Quais problemas você vai resolver para esse paciente?
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Quais problemas você vai assumir a responsabilidade como farmacêutico?
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Houve impacto econômico nas intervenções realizadas?
Não Sim. Especificar:__________________________________________________________________________
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Data Necessidades relacionadas com o medicamento, preocupações, perguntas, expectativas
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Notas de Evolução (avaliação do seguimento):
Data Evolução
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Recomendações na alta hospitalar (medicamentos / terapia não farmacológica):
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Códigos de problemas relacionados ao uso de medicamentos:
Código Tipo Causa
0 Não se conhece nenhuma neste momento
1A Transtorno não tratado
1B Tratamento sinérgico
1C
Indicação
Necessita tratamento
Tratamento profilático
2A Ausência de indicação
2B Adição/consumo de “drogas de abuso”
2C Tratamento não farmacológico apropriado
2D Tratamento duplicado
2E
Indicação
Tratamento
farmacológico não
necessário
Tratamento de RAM evitável
3A Forma de administração inadequada
3B Presença de contraindicação
3C Transtorno resistente ao medicamento
3D Medicamento não indicado ao transtorno
3E
Efetividade
Medicamento
inadequado
Existência de um medicamento mais efetivo
4A Dose inadequada
4B Freqüência inadequada
4C Duração inadequada
4D Armazenamento incorreto
4E Administração incorreta
4F
Efetividade
Subdose
Interação medicamentosa
5A Medicamento perigoso para o paciente
5B Reação alérgica
5C Administração incorreta
5D Interação medicamentosa
5E Aumento/diminuição de dose demasiadamente rápido
5F
Segurança
Reação adversa ao
medicamento
(RAM)
Efeito indesejável
6A Dose inadequada
6B Freqüência inadequada
6C Duração inadequada
6D
Segurança
Sobredose
Interação medicamentosa
7A Medicamento não disponível
7B Recursos não suficientes para adquirir o medicamento
7C Impossibilidade de deglutição/administratação
7D Falta de compreensão
7E
Aderência
Os pacientes preferem não tomar o medicamento
Adaptado de “El Ejercicio de la Atencion Farmaceutica”, Cipolle et al, 1ªed. 2000, Madrid, Espanha.