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Internal identification field: (obligatory)
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Date/PO No. /pharmacotherapeutic follow-up dossier (PTFD) No. |
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Administrative identification field (obligatory)
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Pharmacist: Name, company name, address, phone/fax/e-mail,…
Health care professional(s): Last, first names, specialty, code, address, tel, fax, e-mail
Patient : Last, first names, address |
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Patient profile : (
obligatory when it exists ) :
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Age, biometric and laboratory test data, psychosocial values |
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Nature of the problem (
obligatory when it exists ) : index
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Therapeutic intents of the prescribing physician : free text zone
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Pharmaceutical arguments
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Arguments: free text zone
Proposal: free text zone |
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Decision (obligatory) : Index
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Implementation of the decision
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Notifications: (drug or device monitoring) : (obligatory when it exists ) |
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Specific recommendations: free text zone
Notification : recipient of the information (patient, physician, nurse, other health care professional) |
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Transmission :
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Health care professional(s): Code
Patient: |
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Reference : published works, databases, ministerial circulars, Public Health Code,…
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Signing pharmacist : (obligatory) Title, last, first names, Council of Pharmacists No.
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