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Pharmacist Interviewer:
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| Kip Olson |
| MRN 546481 |
DOB 11/2/1981 |
Age 45 |
Gender Male |
Ethnicity White |
Height 188 cm |
Weight 67.4 kg |
Creatinine 1.6 mg/dL |
| Patient Name: Kip Olson DOB: 11/2/1981 Room: 488 |
Allergies: aspirin (severe rash, runny nose), 6 years ago | Immunization History:
|
| Community Rx Info: Walgreens Rx Insurance: Humana Pharmacy Solutions |
Social History:
|
Name |
(date/time) |
Effects |
for D,H,M |
||||||
0645 |
|||||||||
0830 |
|||||||||
1700 |
|||||||||
2250 |
|||||||||
2250 |
|||||||||
| Additional Notes: CrCl = 56 mL/min based on actual body weight of 67.4 kg (ABW/IBW = 82%) | Action Key: C = Continue *Must provide reason: D = Discontinue, H = Hold, M = Modify |
| Med history obtained by (sign and print): | Date: 05-13-2026 |
| Patient Name: Kip Olson DOB: 11/2/1981 Room: 488 |
Allergies: aspirin (severe rash, runny nose), 6 years ago | Immunization History:
|
| Community Rx Info: Walgreens Rx Insurance: Humana Pharmacy Solutions |
Social History:
|
Name |
(date/time) |
Effects |
for D,H,M |
||||||
0645 |
|||||||||
0830 |
|||||||||
1700 |
|||||||||
2250 |
|||||||||
2250 |
|||||||||
| Additional Notes: | Action Key: C = Continue *Must provide reason: D = Discontinue, H = Hold, M = Modify |
| Med history obtained by (sign and print): | Date: 05-13-2026 |