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Affix patient identification label here

Attach ADR sticker


URN:
See front page for details

REMOVED AREA
Family name:
not a valid
Given names: prescription unless As required
Address: identifiers present
PRN
Date of birth: Sex:  M  F
medications
First prescriber to print patient name Year: 20
and check label correct:
Date Medicine (print generic name)

Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No
Yes / No
Medication chart number of Date

Facility/service: Additional charts

days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
IV fluid BGL/insulin Acute pain Other Time
Ward/unit: Palliative care Chemotherapy IV heparin PRN
Indication Pharmacy Dose
Once only and nurse initiated medicines and pre-medications Route

Yes / No Dispense?
Prescriber / Nurse Initiator (NI)

Duration:

 Date:
Date Medicine Date/time of Time Prescriber signature Print your name Contact
Route Dose Given by Pharmacy
prescribed (print generic name) dose Signature Print your name given Sign

Date Medicine (print generic name)


Date

days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time
PRN
REMOVED AREA

Indication Pharmacy Dose


Route

Yes / No Dispense?

DO NOT WRITE IN THIS BINDING MARGIN


Duration:
Prescriber signature Print your name Contact
Sign

 Pharmacist:
Date Medicine (print generic name)
Date

days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time
PRN
Indication Pharmacy Dose
Route

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact
Sign

 Date:
NIMC (long-stay)
Date Medicine (print generic name)
Date
Telephone orders (to be signed within 24 hours of order)
Record of administration

days Qty:
Date Medicine Check initials Prescriber Pres. Route Dose Hourly frequency Max PRN dose/24 hrs
Route Dose Frequency Date Time / Time / Time / Time / Time
time (print generic name) name sign
N1 N2 given by given by given by given by PRN
Indication Pharmacy Dose
Route

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact
Sign

Date Medicine (print generic name)


Date

days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time

  Print your name:


PRN
Indication Pharmacy Dose
Route

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact
Sign

Medicines taken prior to presentation to hospital Date Medicine (print generic name)
Date
(Prescribed, over the counter, complementary) Own medicines brought in? Y N Administration aid (specify) ..........................
Medicine Dose and frequency Duration Medicine Dose and frequency Duration

days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time
PRN
Indication Pharmacy Dose
Route

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact
Sign

Date Medicine (print generic name)


Date

Prescriber’s signature:
Route Dose Hourly frequency Max PRN dose/24 hrs

days Qty:
Time
PRN
Indication Pharmacy Dose
Route

Dispense?
GP: Community pharmacy:

Duration:
Prescriber signature Print your name Contact
Sign

Sign: Print: Date: Medicines usually administered by:


Check if patient has another medication chart Check if patient has another medication chart
Affix patient identification label here and overleaf
Attach ADR sticker
URN:
Allergies and adverse drug reactions (ADR) Family name:
not a valid

REMOVED AREA
Nil known  Unknown (tick appropriate box or complete details below)
Medicine (or other) Reaction / type / date Initials Given names: prescription unless
Address: identifiers present

Date of birth: Sex:  M  F

First prescriber to print patient name


and check label correct: Weight (kg): Height (cm):
Sign  Print  Date

Regular medicines
Year: 20 Date and month Warfarin education record
Patient educated by:..............................
Date (Marevan / Coumadin) INR result
Warfarin select brand
Sign:......................................................................

Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No Continue on discharge? Yes / No
Yes / No
Route Target INR range Date:......................................................................
Prescriber to enter
Dose

 Date:
individual doses mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg mg Given warfarin book:..............................

days Qty:
Indication Pharmacy
Prescriber Sign:......................................................................
Date:......................................................................
Prescriber signature Print your name Contact 1600
Initial 1

Yes / No Dispense?

REMOVED AREA
Duration:
PRESCRIBER MUST ENTER administration times Initial 2

Date Medicine (print generic name) Tick if Recommended


DO NOT WRITE IN THIS BINDING MARGIN

slow
release administration times
Guidelines only

 Pharmacist:
Route Dose Frequency and NOW enter times

days Qty:
Morning Mane 0800

Indication Pharmacy Night Nocte 1800 or 2000


Twice BD 0800 2000
a day

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact Three times TDS
0800 1400 2000
a day
Regular 6 hrly 0600 1200 1800 2400
6 hourly
Date Medicine (print generic name) Tick if
Regular
slow 8 hrly 0600 1400 2200
release 8 hourly
Four times

 Date:
Route Dose Frequency and NOW enter times QID 0600 1200 1800 2200

days Qty:
a day

Indication Pharmacy
National Long Stay Medication Chart  –  11/2008  –  © Commonwealth of Australia 2005  –  As amended 2008

Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact SR = Sustained, modified
or controlled release
formulation.
Date Medicine (print generic name) Tick if Tick if
slow slow If scored tablet, then half
release
release can be given.
Route Dose Frequency and NOW enter times

days Qty:
Dose must be swallowed
without crushing.

Indication Pharmacy

  Print your name:


Yes / No Dispense?
Duration:
Prescriber signature Print your name Contact
Reason for
not administering
Date Medicine (print generic name) Tick if Codes MUST be circled
slow
release
Route Dose Frequency and NOW enter times Absent

days Qty:
Indication Pharmacy Fasting

Dispense?
Duration:
Prescriber signature Print your name Contact Refused – notify prescriber

Date Medicine (print generic name) Tick if Vomiting


slow
release
Route Dose Frequency and NOW enter times On leave

Continue on discharge? Yes / No


Yes / No

Prescriber’s signature:
Indication Pharmacy Not available – obtain supply

days Qty:
or contact prescriber

Prescriber signature Print your name Contact Withheld – enter reason in


clinical record

Dispense?
Duration:
Self administered
Pharmaceutical review:

Check if patient has another medication chart Check if patient has another medication chart

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