Name:...

Hosp. No.....

DRUG PRESCRIPTION CHART Age/Sex:..

Weight : Kg.

Drug Prescription Chart No: Ward:... Diagnosis:..

ALLERGIES &ADVERSE DRUG REACTIONS

Yes Unknown
INSTRUCTION FOR USE Drug Name
Use Approved names and metric dose. 1.
Order medication in the appropriate section and sign your name to legalized 2.
prescribing.
3.
Any alteration in your drug therapy MUST be ordered with a NEW
ENTRY on the prescription chart. 4.
Discontinue the drugs with a line through the next administration 5.
recording panel and sign.
The nurse administering the drug must initial the appropriate
boxes.
REASON FOR NOT ADMINISTERING DRUGS
Enter the code in the box in the event of the drug not being administered.
Fasting
If patient adversely reacts to medication; observe, inform doctor and
complete ADR form. Refused notify Dr and enter reason in clinical

Use only CAPITAL LETTERS for prescribing Sound-alike drugs. record
Prescribed dose not given the legend to be entered in the given column On leave
Not available obtain supply or contact Dr
MEDICINES TAKEN PRIOR TO PRESENTATION TO HOSPITAL Withheld enter reason in clinical record
(To be compared with every order)
Self administered
Last Dose
S.No Drug Name Dose
Date/Time LIST OF MEDICATIONS THAT RECOMMENDED
REQUIRES AUTOMATIC STOP ADMINISTRATION TIMES
ORDER GUIDELINES ONLY
Medications Days Morning Mane 0800
Night Nocte 1800 or
Oral Anti Infectives 7 2000
Days Twice a day BD 0800 2000
IV Anti Infectives 3 Three times TDS 0800 1400 2000
Days a day
Heparin 3 Regular 6 6hrly 0600 1200 1800 2400
hourly
Days
Regular 8 8hrly 0600 1400 2200
Warfarin 1 Day hourly
Aerosolized Drugs 4 Four times a DID 0600 1200 1800 2200
Days day
SPECIMEN SIGNATURE
Name of DOCTOR / Nurse / Name of DOCTOR/Nurse/ Name of DOCTOR/Nurse/
Sign. Sign. Sign.
Pharmacist Pharmacist Pharmacist

BSH-FN-065, Rev. 4
 REGULAR MEDICATION:
TICK OR CIRCLE TIME. ENTER DATE &
MONTH

Time
DOCTOR MAY TICK OR CIRCLE Given Given Given Given Given Given Given
ADMINISTRATION TIME by by by by by by by

Drug Approved Name Dose (Metric) Route 0600

0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400

BSH-FN-065, Rev. 4
 REGULAR MEDICATION:
TICK OR CIRCLE TIME. ENTER DATE &
MONTH

Time
DOCTOR MAY TICK OR CIRCLE Given Given Given Given Given Given Given
ADMINISTRATION TIME by by by by by by by

Drug Approved Name Dose (Metric) Route 0600

0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Name Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400
Drug Approved Name Dose (Metric) Route 0600
0800
1000
Special instructions Frequency 1200
1400
1800
Date Doctors Signature Pharmacy 2000
2200
Time 2400

BSH-FN-065, Rev. 4
 AS ACQUIRED AND VARIABLE DOSE MEDICATION
Time Date Dose Given by Time Date Dose Given by
DOCTOR MAY ENTER MEDICATION TIME
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time
Drug Approved Name Dose (Metric) Route

Special Instructions Frequency

Date Doctors Signature Pharmacy

Time

BSH-FN-065, Rev. 4
 PRN MEDICATION Given Given Given Given Given Given Given
by by by by by by by
Date Drug Approved Name Date

Route Frequency Max Time

PRN Dose/24hrs
Indication
Sign
Prescribers Signature Pharmacy

Date Drug Approved Name Date

Route Frequency Max Time

PRN Dose/24hrs
Indication
Sign
Prescribers Signature Pharmacy

Date Drug Approved Name Date

Route Frequency Max Time

PRN Dose/24hrs
Indication
Sign
Prescribers Signature Pharmacy

Date Drug Approved Name Date

Route Frequency Max Time

PRN Dose/24hrs
Indication
Sign
Prescribers Signature Pharmacy

Date Drug Approved Name Date

Route Frequency Max Time

PRN Dose/24hrs
Indication
Sign
Prescribers Signature Pharmacy

TELEPHONE ORDER (To be signed within 24 hours of order)

Drug Approved RECORD OF Doctors
Date/Time Route Dose Taken by Doctors Name Pharmacy
Name ADMINISTRATION Signature/Time
Date/Time Given by

Date WARFARIN INR Result

Route Prescriber to enter Target INR Dose mg mg mg mg mg mg
individual doses Range
Indication Pharmacy Date
Prescribers Signature 1800
(Nurse 1)
Nurse 2

BSH-FN-065, Rev. 4
 Time

Time

Time

Time

Time
Topical drug administration Given by Given Given Given Given
by by by by
Drug Approved Name Dose (Metric) Route

Special instructions Frequency

Date Doctors Name Pharmacy

Drug Approved Name Dose (Metric) Route

Special instructions Frequency

Date Doctors Name Pharmacy

Drug Approved Name Dose (Metric) Route

Special instructions Frequency

Date Doctors Name Pharmacy

Drug Approved Name Dose (Metric) Route

Special instructions Frequency

Date Doctors Name Pharmacy

Drug Approved Name Dose (Metric) Route

Special instructions Frequency

Date Doctors Name Pharmacy

ONCE ONLY AND PRE-ANAESTHETIC MEDICATIONS

Dose Doctors
Date Time Drug Approved Name Route Given by Time Pharmacy
(Metric) Signature

Discharge / leave / medication

Date of discharge:

Drug (Approved Name) Dose and Frequency No. of days supply Pharmacy

Doctors Signature Date Dispensed by Checked by

BSH-FN-065, Rev. 4