Subjective | | Identifies CC and summarizes HPI, PMH, SH, FH | CC: HPI:PMH: SH:FH:Meds: AllergiesLabs:Calculations:Pertinent PE: | *Complete medication list; Allergies (important) | | Objective Data | | Calculations (IBW, BMI, *CrCl) as appropriate to case | | Pertinent physical exam findings/lab data (pos/neg); *assesses renal /hepatic fxn as indicated | | Problem List | | Identifies each health problem and related DRP (IESC) (current and potential) and prioritizes-must include address patients concerns | 1.2.3. | Assessment (A) | | Identifies causes/contributing factors, prognostic indicators/ risk factors, differential dx and/ or non-contributing factors as appropriate | 1. a. CF/RF/other b. goals – acute/ long term c. Drug- why this one 2. d. CF/RF/other e. goals - Long term / acute f. Drug- why this one 3. g. CF/RF/other h. goals - Long term / acute i. Drug- why this one | Identifies goals of therapy | | Selects drug therapy; provides rationale | | Plan (P) | | Specifies new therapy and modifies existing drug therapy as indicated (*dose, frequency, route, and duration as appropriate) | 1. Start/stop/change to/switch [dose, frequency, route, and duration as appropriate] a. Monitor for adverse effects, signs of toxicity, efficacy endpoints (how often and when) b. Non pharm strategies c. Follow up (to whom, when, for what) 2. Start/stop/change to/switch [dose, frequency, route, and duration as appropriate] d. Monitor for adverse effects, signs of toxicity, efficacy endpoints (how often and when) e. Non pharm strategies f. Follow up (to whom, when, for what) 3. Start/stop/change to/switch [dose, frequency, route, and duration as appropriate] g. Monitor for adverse effects, signs of toxicity, efficacy endpoints (how often and when) h. Non pharm strategies i. Follow up (to whom, when, for what)Patient education :