portfolio - New Record

Begin a New Portfolio

Note: all online portfolio's must have a Portfolio ID#.

New Portfolio's must also include your name (as entered in your log-in) and PIN# in the spaces provided. Please email Professor Dahm (sdahm@ku.edu) when you have completed a new portfolio.

Initial Visit Interview

Student Name:

Password (PIN#):

Portfolio ID#:

Patient Initials:

Date of Visit:

Patient Age:

Race:

Gender:

Reason for Visit:

History of Present Illness:

Past Medical History:

Educational, Occupational, Social, Family History:

Surgical History:

Diet & Exercise History:

Patient Understanding of Condition:

Physical Exam

CV:

HEENT:

Chest:

Neuro:

GI:

GU:

Musculo-Skeletal:

Mental:

General:

Allergies, Intolerances, Reactions:

Social Drug Use (alcohol, caffeine, tobacco, other):

Preceptor Comments #1:

Lab Data

DATE:

DATE:
(will automatically fill w/dates at left)

T Prot:

Trig:

Alb:

TSH:

Hgb:

INR:

Hct:

PTT:

WBC:

PT:

PLT:

Glu:

AST:

BUN:

ALT:

Cr:

LDH:

K:

Alk Phos:

Cl:

HbAlc:

CO2:

LDL:

Na:

HDL:

Ca:

Tot Chol:

Phos:

Additional Lab Data:

(Please calculate and record Ideal Body Weight and Creatinine Clearance)

Vital Signs

DATE:
(will automatically fill with dates above)

Wt (kg):

Ht (cm):

Temp:

BP:

Pulse:

Drug Serum Concentrations

Digoxin:

Theo:

Gent/Tob:

Vanco:

Phenytoin:

Other:

Current Drug Therapy: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication
(Generic and Trade Name are Required)

1:

2:

3:

4:

5:

6:

7:

8:

9:

10:

11:

12:

13:

14:

15:

List Medications used Unsuccessfully to Treat Current Conditions: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication (Generic and Trade Name are Required)

1:

2:

3:

4:

5:

6:

7:

8:

Herbal Medications: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication

1:

2:

3:

4:

5:

6:

Patient Clinical Problem List & Care Plan - Prioritized Medical Problem List

1.

2.

3.

4.

5.

6.

List each problem and identify the therapeutic goal and specific endpoints. support your identification of each problem with evidence from the literature. For each problem make recommendation and identify recommended monitoring parameters. Be sure to document the outcomes!

Pharmacotherapy Problem #1: (auto fill)

Medications used to treat problem #1:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Pharmacotherapy Problem #2: (auto fill)

Medications used to treat problem #2:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Pharmacotherapy Problem #3: (auto fill)

Medications used to treat problem #3:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Pharmacotherapy Problem #4: (auto fill)

Medications used to treat problem #4:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Pharmacotherapy Problem #5: (auto fill)

Medications used to treat problem #5:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Pharmacotherapy Problem #6: (auto fill)

Medications used to treat problem #6:

Assessment of patient's current therapy:

Patient goal and specific endpoints:

Supportive medical evidence from literature:

Recommendations to reach goal:

Monitoring parameters and frequency:

Intervention documentation and outcome:

Preceptor Comments #2:

Drug Therapy Progress Notes:

Pt: (auto-fill)

Pharmacist:

Location:

List Date - Problem - Actions:

1:

2:

3:

4:

Portfolio Summary - Summarize this patient's case in your own words and email to Professor Dahm at sdahm@ku.edu. Provide a brief introduction to the case and tell us your impression of the overall care of this patient.

Preceptor Comments #3:

Please email your assigned KU-based preceptor when you have completed a new portfolio or have edited a current portfolio
and are ready to have it reviewed.

It is highly recommended that you PRINT this page before pressing the "SAVE" button.

(this form is for reference only, not for actual submission)

Return to Home Page

Initial Visit Interview
Student Name:
Password (PIN#):
Portfolio ID#:
Patient Initials:
Date of Visit:
Patient Age:
Race:
Gender:
Reason for Visit:
History of Present Illness:
Past Medical History:
Educational, Occupational, Social, Family History:
Surgical History:
Diet & Exercise History:
Patient Understanding of Condition:

Physical Exam
CV:
HEENT:
Chest:
Neuro:
GI:
GU:
Musculo-Skeletal:
Mental:
General:
Allergies, Intolerances, Reactions:
Social Drug Use (alcohol, caffeine, tobacco, other):
Preceptor Comments #1:

Lab Data
DATE:	DATE:	(will automatically fill w/dates at left)

T Prot:	Trig:
Alb:	TSH:
Hgb:	INR:
Hct:	PTT:
WBC:	PT:
PLT:	Glu:
AST:	BUN:
ALT:	Cr:
LDH:	K:
Alk Phos:	Cl:
HbAlc:	CO2:
LDL:	Na:
HDL:	Ca:
Tot Chol:	Phos:
Additional Lab Data: (Please calculate and record Ideal Body Weight and Creatinine Clearance)

Vital Signs
DATE:	(will automatically fill with dates above)

Wt (kg):
Ht (cm):
Temp:
BP:
Pulse:
Drug Serum Concentrations
Digoxin:
Theo:
Gent/Tob:
Vanco:
Phenytoin:
Other:

Current Drug Therapy: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication (Generic and Trade Name are Required)
1:
2:
3:
4:
5:
6:
7:
8:
9:
10:
11:
12:
13:
14:
15:
List Medications used Unsuccessfully to Treat Current Conditions: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication (Generic and Trade Name are Required)
1:
2:
3:
4:
5:
6:
7:
8:
Herbal Medications: Drug Name/Dose/Strength/Route - Schedule/Duration - Indication
1:
2:
3:
4:
5:
6:

Patient Clinical Problem List & Care Plan - Prioritized Medical Problem List
1.
2.
3.
4.
5.
6.

Drug Therapy Progress Notes:
Pt: (auto-fill)	Pharmacist:	Location:
List Date - Problem - Actions:
1:
2:
3:
4:
Portfolio Summary - Summarize this patient's case in your own words and email to Professor Dahm at sdahm@ku.edu. Provide a brief introduction to the case and tell us your impression of the overall care of this patient.
Preceptor Comments #3: