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HOSPITAL UNIVERSITÁRIO PROF. EDGARD SANTOS

SERVIÇO DE FARMÁCIA FICHA DE SEGUIMENTO FARMACÊUTICO

Nome:__________________________________________________

Reg.:_____________

Data: ____/_____/____

Unidade/leito:________/________

Admissão:____/____/____

Médico responsável:

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Óbito: Não Sim

Data : _____/_____/_____

Alta: _____/_____/_____

Farmacêutico responsável:

____________________________CRF________

Endereço:_________________________________________________________________

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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?

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Quais exames são necessários para determinar se a terapia atual está causando toxicidade?

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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.