Documente Academic
Documente Profesional
Documente Cultură
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
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
days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time
PRN
REMOVED AREA
Yes / No Dispense?
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
days Qty:
Route Dose Hourly frequency Max PRN dose/24 hrs
Time
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
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
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
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
slow
release administration times
Guidelines only
Pharmacist:
Route Dose Frequency and NOW enter times
days Qty:
Morning Mane 0800
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
days Qty:
Indication Pharmacy Fasting
Dispense?
Duration:
Prescriber signature Print your name Contact Refused – notify prescriber
Prescriber’s signature:
Indication Pharmacy Not available – obtain supply
days Qty:
or contact prescriber
Dispense?
Duration:
Self administered
Pharmaceutical review:
Check if patient has another medication chart Check if patient has another medication chart