National inpatient medication chart by derrickcizzle

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									AFFIX PATIENT IDENTIFICATION LABEL HERE AND OVER LEAF

AS REQUIRED “PRN” MEDICINES
A t t a c h A D R S t i ck e r
See front page for details

UR No.: Family Name: Given Names: D.O.B.:

NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT
Sex: M F

Ward / U n i t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Weight (kg)
Date Medicine (Print Generic Name)

1st Prescriber to Print Patient Name and Check Label Correct: .................................................
Date Prescriber’s Signature.....................................................Print Name ...............................................................Pager ........................Date .................................... Pharmacist .......................................................................Date ...................................

PAEDIATRIC MEDICINE CHART ........ of ........
Fa c i l i t y / S e r v i c e : _______________________
Ward / U n i t : ....................................................................................... ADDITIONAL CHARTS IV Fluid BGL/Insulin Inhalation Chemotherapy Acute Pain/P.C.A. Palliative Care IV Heparin Other

Route

DOSE

Hourly Frequency

Pharmacy/Additional Information

DOSE

Duration?..........days/Qty?..........

Continue on discharge Yes / No

PRN

Max DOSE/24 hrs

Time

ONCE ONLY MEDICINES
Date Prescribed Medicine (Print Generic Name) Route DOSE Date/Time to be given Prescriber Signature Print Name DOSE calc e.g. mg/kg per DOSE Given by Date/Time Pharm Given

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Route

Prescriber Signature

Print Name

Contact/Pager

Sign

Date

Medicine (Print Generic Name)

Date

NOT A VALID ORDER UNLESS LEGIBLE

Route

DOSE

Hourly Frequency

Pharmacy/Additional Information

DOSE

Duration?..........days/Qty?..........

Continue on discharge Yes / No

PRN

Max DOSE/24 hrs

Time

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Route

Prescriber Signature

Print Name

Contact/Pager

Sign

Date

Medicine (Print Generic Name)

Date

Route

DOSE

Hourly Frequency

Pharmacy/Additional Information

DOSE

Duration?..........days/Qty?..........

Continue on discharge Yes / No

PRN

Max DOSE/24 hrs

Time

Dispense Yes / No

BINDING MARGIN - DO NOT WRITE

BINDING MARGIN - DO NOT WRITE

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Route

TELEPHONE ORDERS (To be signed within 24 hrs of order)
Date Time Medicine (use Generic Names) Print Route Dose Frequency Nurse Initials Nr 1/Nr 2 Dr Name Dr Sign Date RECORD OF ADMINISTRATION
Time/Given by: Time/Given by: Time/Given by: Time/Given by:

PAEDIATRIC MEDICINE CHART

Prescriber Signature

Print Name

Contact/Pager

Sign

Date

Medicine (Print Generic Name)

Date

Route

DOSE

Hourly Frequency

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Paediatric National Short Stay Med Chart: 12/06 - 12187

Pharmacy/Additional Information

DOSE

Duration?..........days/Qty?..........

Continue on discharge Yes / No

PRN

Max DOSE/24 hrs

Time

Dispense Yes / No

Route

Medicines taken Prior to Presentation to Hospital (Prescribed, over the counter, complementary) Own medicines brought in?
Medicine & Formulation Dose & Frequency Duration

Y

N Dose & Frequency Duration

Prescriber Signature

Print Name

Contact/Pager

Sign

Medicine & Formulation

Date

Medicine (Print Generic Name)

Date

Route

DOSE

Hourly Frequency

Pharmacy/Additional Information

DOSE

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Route

Duration?..........days/Qty?..........

Continue on discharge Yes / No

PRN

Max DOSE/24 hrs

Time

Dispense Yes / No

RATION MINIST FOR AD NOT
Doctor/GP: C o m mu n i t y P h a r m a c y : Documented by: (Sign) (Date) Medicines usually administered by:

Prescriber Signature

Print Name

Contact/Pager

Sign

H o s p i t a l O n ly P r e s c r i p t i o n

H o s p i t a l O n ly P r e s c r i p t i o n

A t t a c h A D R S t i ck e r
ALLERGIES & ADVERSE DRUG REACTIONS (ADR)
N i l k n ow n U n k n ow n (tick appropriate box or complete details below)

AFFIX PATIENT IDENTIFICATION LABEL HERE AND OVER LEAF UR No.: Family Name: Given Names: D.O.B.:

Drug (or other)

Reaction/Type/Date

Initials

NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT
Sex: M F

COMPLETE ALERT SHEET IN MEDICAL RECORD
S i g n ........................................... P r i n t ......................................... Date ...................

1 s t P r e s c r i b e r t o p r i n t p a t i e n t n a m e & c h e ck l a b e l c o r r e c t : .............................................................. We i g h t ( k g ) B.S.A.(m2)............................................ H e i g h t ( c m )......................................... G e s t a t i o n a l A g e (wks)........................
Prescriber’s Signature.....................................................Print Name ...............................................................Pager.........................Date.................................... Pharmacist .......................................................................Date ..........................

REGULAR MEDICINES
YEAR 20_____ DATE & MONTH PRESCRIBER MUST ENTER ADMINISTRATION TIMES
Duration?........................days/Qty?......................... Date Medicine (Print Generic Name) Prescriber’s Signature.....................................................Print Name ...............................................................Pager.........................Date.................................... Pharmacist .......................................................................Date ..........................

REGULAR MEDICINES
YEAR 20_____ DATE & MONTH PRESCRIBER MUST ENTER ADMINISTRATION TIMES
Tick if Slow Release
Date Medicine (Print Generic Name)

Tick if Slow Release

Route

DOSE

Frequency & now enter times

Route

DOSE

Frequency & now enter times

Continue on discharge Yes / No

Pharmacy/Additional Information

Pharmacy/Additional Information

Dispense Yes / No

NOT A VALID ORDER UNLESS LEGIBLE

Prescriber Signature

Print Name

Contact/Pager

RECOMMENDED ORAL ADMINISTRATION TIMES
GUIDELINES ONLY Morning Night Mane 0800 Nocte 1800 or 2000

Prescriber Signature

Print Name

Contact/Pager

Tick if Slow Release

Duration?........................days/Qty?.........................

Tick if Slow Release

Route

DOSE

Frequency & now enter times

Pharmacy/Additional Information

Continue on discharge Yes / No

Pharmacy/Additional Information

Prescriber Signature

Print Name

Contact/Pager

Dispense Yes / No

Prescriber Signature

Print Name

Contact/Pager

Tick if Slow Release

Duration?........................days/Qty?.........................

Tick if Slow Release

Route

DOSE

Frequency & now enter times

Route

DOSE

Frequency & now enter times

Pharmacy/Additional Information

Continue on discharge Yes / No

Pharmacy/Additional Information

Prescriber Signature

Print Name

Contact/Pager

Dispense Yes / No

Prescriber Signature

Print Name

Contact/Pager

REASON FOR NOT ADMINISTERING Codes MUST be circled

Duration?........................days/Qty?.........................

Tick if Slow Release

Absent Fasting Refused - Notify Dr Vomiting On leave Not available - obtain supply or contact Dr Withheld - Enter reason in Clinical Record Self Administration Parent/Carer Administration

A F R V L N

Tick if Slow Release

Route

DOSE

Frequency & now enter times

Route

DOSE

Frequency & now enter times

Pharmacy/Additional Information

Pharmacy/Additional Information

Dispense Yes / No

Prescriber Signature

Print Name

Contact/Pager

W S P

Prescriber Signature

Print Name

Contact/Pager

P h a r m a c i s t R ev i ew :

P h a r m a c i s t R ev i ew :

H o s p i t a l O n ly P r e s c r i p t i o n

H o s p i t a l O n ly P r e s c r i p t i o n

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Duration?........................days/Qty?.........................

Date

Medicine (Print Generic Name)

Date

Medicine (Print Generic Name)

Continue on discharge Yes / No

Continue on discharge Yes / No

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Tick if Slow release

SR=Sustained or modified release formulation. If tablet is scored, then half can be given. Dose must be swallowed without crushing.

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Duration?........................days/Qty?.........................

Date

Medicine (Print Generic Name)

Date

Medicine (Print Generic Name)

Continue on discharge Yes / No

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Continue on discharge Yes / No

Twice BD 0800 2000 a day Three times TDS 0800 1400 2000 a day Four times QID 0800 1200 1700 2100 a day

Route

DOSE

Frequency & now enter times

Duration?........................days/Qty?.........................

Date

Medicine (Print Generic Name)

Date

Medicine (Print Generic Name)

Dispense Yes / No

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Indication

Dose Calculation (e.g. mg/kg per DOSE)

Duration?........................days/Qty?.........................

Continue on discharge Yes / No


								
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