Adult Acute NIMC - Medication Chart PDF

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Summary

Medication Chart...

Description

Affix patient identification label here

Attach ADR sticker URN:

See front page for details

Not a valid prescription unless identifiers present Sex:

M

Hourly frequency

Date Max PRN dose/24 hrs Time

PRN Indication

Pharmacy

Prescriber signature

Print your name

Date

Medicine (print generic name)

Route

Dose

Hourly frequency

Dose Route Contact

Date Max PRN dose/24 hrs Time

PRN Indication

Sign

Pharmacy

Dose Route

Prescriber signature

Print your name

Date

Medicine (print generic name)

Route

Dose

Hourly frequency

Contact

Sign Date

Max PRN dose/24 hrs

Time

PRN Indication

Pharmacy

Dose Route

Prescriber signature

Print your name

Medicine (print generic name)

Route

Dose

Hourly frequency

Sign Date

Max PRN dose/24 hrs Time

PRN Indication

Pharmacy

Dose Route

Prescriber signature

Print your name

Date

Medicine (print generic name)

Route

Dose

Hourly frequency

Contact

Sign Date

Max PRN dose/24 hrs Time

PRN Indication

Pharmacy

Dose Route

Prescriber signature

Print your name

Date

Medicine (print generic name)

Route

Dose

Hourly frequency

Contact

Sign Date

Max PRN dose/24 hrs Time

PRN Pharmacy

Dose Route

Prescriber signature

Print your name

Date

Medicine (print generic name)

Route

Dose

Hourly frequency

Contact

Sign Date

Max PRN dose/24 hrs Time

PRN Indication Prescriber signature

Pharmacy Print your name

Dose Route Contact

Sign

Ward/unit:

BGL/insulin Chemotherapy

of Acute pain IV heparin

Other

Once only and nurse initiated medicines and pre-medications Date prescribed

Medicine (print generic name)

Route

Prescriber/Nurse Initiator (NI) Date/time of Given by dose Signature Print your name

Dose

Time given

Pharmacy

Telephone orders (to be signed within 24 hours of order) Date time

Medicine (print generic name)

Check initials Route

Dose Frequency

N1

N2

Prescriber Pres. sign name

Date

Record of administration Time / Time / Time / Time / given by given by given by given by

Medicines taken prior to presentation to hospital Own medicines brought in? Y N Dose and frequency Duration Medicine

(Prescribed, over the counter, complementary)

Medicine © Commonwealth of Australia 2005 – As amended 2019

Indication

Additional charts IV fluid Palliative care

GP: Sign:

Administration aid (specify) .......................... Dose and frequency Duration

Community pharmacy: Print:

Date:

Medicines usually administered by:

NIMC (acute)

Date

Contact

Medication chart number Facility/service:

DO NOT WRITE IN THIS BINDING MARGIN

Dose

DO NOT WRITE IN THIS BINDING MARGIN

Route

Date:

Medicine (print generic name)

Pharmacist:

Date

F

Year: 20

First prescriber to print patient name and check label correct:

Date:

Date of birth:

Cut off section

As required PRN medicines

Print your name:

Address:

Prescriber’s signature:

Given names:

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 Dispense? Yes / No Dispense? Yes / No Dispense? Yes / No Dispense? Yes / No Dispense? Yes / No Dispense? Yes / No Dispense? Yes / No Duration: days Qty: Duration: days Qty: Duration: days Qty: Duration: days Qty: Duration: days Qty: Duration: days Qty: Duration: days Qty:

Family name:...