Appendix E - Example Care Plan with Missing Data

Mock Patient Name:

Preferred Pronoun:

Mock MRN:

Age:

Sex Assigned at Birth:

Height:

Race:

Gender:

Weight:

Ethnicity:

Preferred Pharmacy:

PCP:

Insurance:

Allergies/Intolerances/ADRs

HPI, FH, SH, Social Determinants of Health, Health Literacy

□ No known drug allergies/ADRs

□ Not known/inadequate information

Drug

Reaction

Additional Information:

Prioritized Medical Problem List

Medication Profile

1

2

3

4

5

6

Health Maintenance:

PMH with no therapy needed:

Inadequate Database:

Vital Signs, Laboratory Data, and Diagnostic Test Results

Normal Range or Units

Day

Today

Weight

lbs (kg)

Temperature

^oC

Blood Pressure

mmHg

Pulse

Respiratory Rate

Na

135–145 mEq/L (135–145 mmol/L)

K

3.3–4.9 mEq/L (3.3–4.9 mmol/L)

Cl

97–110 mEq/L (97–110 mmol/L)

CO₂/HCO₃

22–26 mEq/L (22–26 mmol/L)

BUN

8–25 mg/dl (2.9–8.9 mmol/L)

Serum Creatinine (adult)

male 0.7–1.3 mg/dl; female 0.6–1.1 mg/dl (male 62–115 m µmol/L; female 53–97 µmol/L)

Creatinine Clearance (adult)

85–135 mL/min (1.42–2.25 mL/s)

Glucose (fasting)

65–109 mg/dl (3.6–6.0 mmol/L)

Total Ca

8.6–10.3 mg/dl (2.15–2.58 mmol/L)

Mg

1.3–2.2 mEq/L (0.65–1.10 mmol/L)

PO₄

2.5–4.5 mg/dl (0.81–1.45 mmol/L)

Hemoglobin

male 13.8–17.2 g/dl; female 12.1–15.1 g/dl (male 138–172 g/L; female 121–151 g/L)

Hematocrit

male 40.7–50.3%; female 36.1–44.3% (male 0.407–0.503; female 0.361–0.443)

MCV

80.0–97.6 µm³ (80.0–97.6 fL)

WBC

4–10 × 10³/mm³ (4–10 × 10⁹/L)

WBC Differential

% polymorphonuclear neutrophils (PMN)/eosinophils/basophils/lymphocytes/monocytes

////

/ / / /

/ / / /

Platelets

140–440 × 10³/mm³ (140–440 × 10⁹/L)

Albumin

3.5–5 g/dl (35–50 g/L)

Bilirubin (total)

0.3–1.1 mg/dl (5.13–18.80 µmol/L)

Bilirubin (direct)

0–0.3 mg/dl (0–5.1 µmol/L)

AST

11–47 IU/L (0.18–0.78 µkat/L)

ALT

7–53 IU/L (0.12–0.88 µkat/L)

Alk phos (adult)

38–126 IU/L (0.13–2.10 µkat/L)

PH

7.35–7.45

PO₂

70–95 mmHg (9.3–12.6 kPa)

O₂

Saturation (90–110%)

PCO₂

35–45 mmHg (4.7–6.0 kPa)

Urine HCG

Additional Notes:

DRUG THERAPY PROBLEM WORKSHEET

Type of Problem

Possible Causes

Problem List

Notes

Correlation between drug therapy and medical problems

Drugs without obvious medical indications

Medication(s) unidentified

Untreated medical conditions

Need for additional drug therapy

New medical condition requiring new drug therapy

Chronic disorder requiring continued drug therapy

Condition best treated with combination drug therapy

May develop new medical condition without prophylactic or preventative therapy or premedication

Unnecessary drug therapy

Medication(s) with no valid indication or condition is better treated with nondrug therapy

Condition caused by accidental or intentional ingestion of toxic amount of drug(s) or chemicals

Medical problem(s) associated with use of or withdrawal from alcohol, drugs, or tobacco

Taking multiple drugs when single agent is as effective

Taking drug(s) to treat an avoidable adverse reaction from another medication

Appropriate drug selection

Current regimen not usually as effective or safe as other choices

Therapy not individualized to patient

Wrong drug

Medical problem for which drug is not effective

Patient has risk factors that contraindicate use of drug

Patient has infection with organisms resistant to drug

Patient refractory to current drug therapy

Taking combination product when single agent appropriate

Dosage form inappropriate or medication error

Drug regimen

PRN use not appropriate for condition

Route of administration/dosage form/mode of administration not appropriate for current condition

Length or course of therapy not appropriate

Drug therapy altered without adequate therapeutic trial

Dose or interval flexibility not appropriate

Dose too low

Dose or frequency too low to produce desired response in this patient

Serum drug concentration below desired goal range for indication

Timing of antimicrobial prophylaxis not appropriate

Medication not stored properly or medication error

Dose too high

Dose or frequency too high for this patient

Serum drug concentration above the desired goal range for indication

Dose escalated too quickly

Dose or interval flexibility not appropriate for this patient

Medication error

Therapeutic duplication

Receiving multiple agents without added benefit

Drug allergy/adverse drug events

History of allergy or ADE to current (or chemically related) agents

Allergy or ADE history not in medical records

Patient not using alert for severe allergy or ADE

Symptoms or medical problems that may be drug induced

Drug administered too rapidly

Medication error, actual or potential

Interactions (drug-drug, drug-disease, drug-nutrient, drug-laboratory test)

Effect of drug altered due to enzyme induction/inhibition, protein binding alterations, or pharmacodynamic change from another drug patient is taking

Bioavailability of drug altered due to interaction with another drug or food

Effect of drug altered due to substance in food

Patient’s laboratory test altered due to interference from drug(s) the patient is taking

Failure to receive therapy

Patient did not adhere to the drug regimen

Drug not given due to medication error

Patient did not take due to high drug cost/lack of insurance

Patient unable to take oral medication

Patient has no IV access for IV medication

Drug product not available

Financial impact

The current regimen is not the most cost effective

Patient unable to purchase medication(s)/no insurance

Patient knowledge of drug therapy

Patient does not understand the purpose, directions, or potential side effects of the drug regimen

Current regimen not consistent with the patient’s health beliefs

1

2

3

4

5

6

1

2

3

4

5

6