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Patient Counseling Form

Signature/Date: Supervisor: Signature/Date:

Uploaded by

Marifuddin Hussaini
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© © All Rights Reserved
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2K views2 pages

Patient Counseling Form

Signature/Date: Supervisor: Signature/Date:

Uploaded by

Marifuddin Hussaini
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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MESCO COLLEGE OF PHARMACY

OSMANIA GENERAL HOSPITAL


Patient Counseling Documentation Form
(PharmD Internship)
Department: Date:………................……

Date & Time: Department: Unit:

Type of patient: In Patient/Outpatient IP-Number/OP-Number:

Age: Weight: Gender: Male/Female Allergies:

Date of admission: Date of Discharge:

Current Medical Problem (Final Diagnosis):

Current Medication:

0
Laboratory Details :( Only abnormal values):

Diagnosis:

Disease Counseled:
02
-2
Medications prescribed:
S N Drug Name (Brand/Generic) Dose RoA Frequency Duration
19
20

Counseling Steps Followed:Yes No


1. Case sheet reviewed
2. Self introduction done
3. Purpose of counseling informed
4. Initial drug information obtained
5. Patient was warned about taking other
Medications including OTC’s herbal drugs etc
6. Actual counseling done
7. Patient understanding gained towards
Therapy was ascertained
8. Counseling points summarized
Points Covered During Counseling Session

Name and purpose of medication Precautions to be taken


Dosage regimen Storage recommendation
Advice on missed dose Benefits of completing the case
Potential side effects Life style modifications
Significant interactions (Drug-Drug/Drug-Food/Drug-Disease)

Any Major Barrier Involved: Yes No

If Yes, Patient based Provider based System based

Quote Specific Barrier (if any):

If yes, whether barrier was rightly overcome? Yes No

0
Time taken for counseling:
02
Less than 10 min. 10 to 20 min. More than 20 min.
-2
Counseling provided to: Patient Patient’s representative.

If patient’s representative, give reason: Patient is unconscious Language problem


Hearing problem Pediatric patient
Others (please specify)
19

Counseling aids used:


Pictogram Dummy inhaler device
20

Spacer None
Others (please specify)

Counseling’s Material Provided:

Patient Information Leaflet Product Information Leaflet

Pamphlets Others, If yes please specify

Understanding of the patient ascertained: Yes No

Counseling Information:

Name of counseling pharmacist: Signature/Date:

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