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Task2AmandaGroupAmedchart1.pdf
Date Medicine (print generic name) Date
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D ur
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n: da
ys Q
ty :
P re
sc ri b
e r’ s
si g
n a tu
re :
P ri n t
yo u r
n a m
e :
D a te
: P
h a rm
a c is
t:
D a te
:
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
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e?
Ye s
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is pe
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Ye
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D ur
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n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
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D ur
at io
n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Date Medicine (print generic name) Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
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n: da
ys Q
ty :
Route Dose Hourly frequency Max PRN dose/24 hrs Time
Indication Pharmacy Dose
Route Prescriber signature Print your name Contact
Sign
Facility/service:
Ward/unit:
Medication chart number of Additional charts
IV fluid Palliative care
BGL/insulin Chemotherapy
Acute pain IV heparin
Other
Once only and nurse initiated medicines and pre-medications Date
prescribed Medicine
(print generic name) Route Dose
Date/time of dose
Prescriber/Nurse Initiator (NI) Given by
Time given
Pharmacy Signature Print your name
Telephone orders (to be signed within 24 hours of order) Date time
Medicine (print generic name)
Route Dose Frequency Check initials Prescriber
name Pres. sign
Date Record of administration
Time / given by
Time / given by
Time / given by
Time / given byN1 N2
Medicines taken prior to presentation to hospital (Prescribed, over the counter, complementary) Own medicines brought in? Y N Administration aid (specify) ..........................
Medicine Dose and frequency Duration Medicine Dose and frequency Duration
GP: Community pharmacy:
Sign: Print: Date: Medicines usually administered by:
D O
N O
T W
R IT
E I N
T H
IS B
IN D
IN G
M A
R G
IN
D O
N O
T W
R IT
E I N
T H
IS B
IN D
IN G
M A
R G
IN
N IM
C (a
c u
te )
PRN
PRN
PRN
PRN
PRN
PRN
PRN
URN:
Family name:
Given names:
Address:
Date of birth: Sex: M F
Not a valid prescription unless
tifiers present
Affix patient identification label here
As required PRN
medicines
See front page for details
Year: 20First prescriber to print patient name and check label correct:
Attach ADR sticker
© C
o m
m o n w
ealth o
f A u stralia 2
0 0 5 – A
s am en
d ed
2 0 1 9
X
Amanda Singh Dr J Spock
USC Hospital
Emergency Department
21
1 1
Singh
Amanda
24 Railway Lane, Nambour, 4560, QLD
25/12/1991
01345980134598
Regular medicines Year 20 Date and month
C on
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e?
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is pe
ns e?
Ye
s /
N o
D ur
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n: da
ys Q
ty :
P re
sc ri b
e r’ s
si g
n a tu
re :
P ri n t
yo u r
n a m
e :
D a te
: P
h a rm
a c is
t:
D a te
:
PRESCRIBER MUST ENTER administration times Date Medicine (print generic name)
Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date Medicine (print generic name)
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date Medicine (print generic name)
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Pharmaceutical review:
Tick if slow
release
Tick if slow
release
Tick if slow
release
Tick if slow
release
Tick if slow
release
Tick if slow
release
Regular medicines
C on
tin ue
o n
di sc
ha rg
e?
Ye s
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o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
P re
sc ri b
e r’ s
si g
n a tu
re :
P ri n t
yo u r
n a m
e :
D a te
: P
h a rm
a c is
t:
D a te
:
Year 20 Date and month Variable dose medicine Drug level Date Medicine (print generic name) Time level taken
Dose Route Frequency
Prescriber to enter dose times and individual dose Prescriber
Indication Pharmacy Time to be given:
......................
Prescriber signature Print your name Contact Time given
VTE risk assessed: Yes Prophylaxis not required Contraindicated Signature: Date: Date Medicine (print generic name)
Route Dose Frequency and NOW enter times
Indication
VTE prophylaxis Pharmacy
Prescriber signature Print your name Contact
Mechanical prophylaxis
Prescriber/NI signature Print your name Contact
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
AM check
PM check
Date Warfarin Marevan / Coumadin select brand
Route Prescriber to enter individual doses
Target INR Range
Indication Pharmacy
Prescriber signature Print your name Contact
PRESCRIBER MUST ENTER administration times
INR Result
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
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is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :Dose mg mg mg mg mg mg mg mg mg mg mg
Prescriber
1600 Initial 1
Initial 2
Date Medicine (print generic name)
Co nt
in ue
o n
di sc
ha rg
e? Y
es /
N o
D is
pe ns
e?
Ye s
/ N o
D ur
at io
n: da
ys Q
ty :
Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date Medicine (print generic name)
Co nt
in ue
o n
di sc
ha rg
e? Y
es /
N o
D is
pe ns
e?
Ye s
/ N o
D ur
at io
n: da
ys Q
ty :
Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Date Medicine (print generic name)
C on
tin ue
o n
di sc
ha rg
e?
Ye s
/ N
o D
is pe
ns e?
Ye
s /
N o
D ur
at io
n: da
ys Q
ty :
Route Dose Frequency and NOW enter times
Indication Pharmacy
Prescriber signature Print your name Contact
Pharmaceutical review:
Recommended administration times
Guidelines only
Morning Mane 0800
Night Nocte 1800 or 2000
Twice a day BD 0800 2000
Three times a day TDS 0800 1400 2000
Regular 6 hourly 6 hrly 0600 1200 1800 2400
Regular 8 hourly 8 hrly 0600 1400 2200
Four times a day QID 0600 1200 1800 2200
Reason for not administering
Codes MUST be circled
Absent
Fasting
Refused – notify prescriber
Vomiting
On leave
Not available – obtain supply or contact prescriber
Withheld – enter reason in clinical record
Self administered
SR = Sustained, modified or controlled release formulation.
If scored tablet, then half can be given.
Dose must be swallowed without crushing.
Tick if slow
release
URN:
Family name:
Given names:
Address:
Date of birth: Sex: M F
Not a valid prescription unless
ers present
Affix patient identification label here and overleaf
Allergies and adverse drug reactions (ADR) Nil known Unknown (tick appropriate box or complete details below)
Medicine (or other) Reaction / type / date Initials
Sign Print Date
First prescriber to print patient name and check label correct: Weight (kg): Height (cm):
Tick if slow
release
Tick if slow
release
Tick if slow
release
Attach ADR sticker
Anticoagulant education record Medicine:
Education
Provided Declined Not appropriate
Written information
Provided Declined
Written information provided: CMI Other:
Signature:
Designation: Date:
21 xx xx
IM
????
Julie Spock 3161JSpock
xx/xx/21
0800
inhale
????
Julie Spock 3161JSpock
xx/xx/21
IV
????
0800
X
65 167
X
Julie Spock xx/xx/21JSpock
JSpock Julie Spock 3161
21
Amanda Singh JSpock
xx/xx/21
0134598
Singh
Amanda
24 Railway Lane, Nambour, 4560, QLD
25/12/1991
x JSpock xx/xx/21
Betamethasone
Salmeterol
Flucloxacillin
5.7 mg Once a week on Monday
50 microg daily
500 mg 6 hrly
0000 0600 1200 1800
X X
xx/xx/21 0.9% Normal Saline
NEB QID
0600
1200 1800 2200
5mls
????
JSpock Julie Spock 3161
