Chart No. this admission Drug Prescription and Administration Record Patient s Name: of Admission: Chart Start : Chart Finish : NHS No: Consultant Code: Ward: ALERT: of Birth: ADDITIONAL CAUTIONS FOR PRESCRIBING (e.g. renal failure, gastric ulceration etc) Tick if on CHEMOTHERAPY OTHER CHARTS in use Tick Box: Syringe driver Opioid patch Other Other DRUG SENSITIVITIES & REACTIONS ature: : ONCE ONLY / NURSE LED PRESCRIPTIONS See Approved Homely Remedies list Medicine Dose Route Instructions Start time Doctor s signature Time given Nurse s signature REMOTE PRESCRIPTIONS File Emergency Telephone Prescription of Drugs form in notes and document any doses given here Medicine Dose Route Instructions Time given Specify text/ email etc Nurse s signature Dr. signature (next working day) CODE FOR USE ON REGULAR AND PRN CHART R = drug refused by patient N = drug not in stock U = patient too unwell W = drug withheld O = patient out P = patient self-administration
INTRAVENOUS THERAPY AND SUBCUTANEOUS INFUSION FOR INFUSION FLUIDS, BLOOD, PLASMA AND DRUGS BY ONE CONTINUOUS INFUSION No additions to be made to blood products or sodium bicarbonate. For information on additive compatibilities contact acy Medicines Information. Infusion Fluid Additions to Infusion Time to Run or ml/hr Prescriber s signature Batch No. Pump Asset No. Time start Nurses signiture x2 Time end Amount infused Type/Strength Volume Route / Site Drug Dose Print name
DRUG SENSITIVITIES: DIAGNOSIS: Route Key IM = Intramuscular SC = Subcutaneous TOP = Topical NEB = Nebulised INH = Inhalation IV = Intravenous PR = Per Rectum PO = Oral / Enteral SL = Sublingual PV = Per Vaginam PEG = Percutaneous endoscopic gastrostomy BUC = Buccal TD = Transdermal NAS = Nasal REGULAR PRESCRIPTIONS MONTH DATE Drug Dose Route Frequency Start Special Instruction / Indication 0800 1800 Drug 0800 Dose Route Frequency Start Special Instruction / Indication 1800 Drug 0800 Dose Route Frequency Start Special Instruction / Indication 1800 Drug 0800 Dose Route Frequency Start Special Instruction / Indication 1800 Drug 0800 Dose Route Frequency Start Special Instruction / Indication 1800 Drug 0800 Dose Route Frequency Start Special Instruction / Indication 1800
REGULAR PRESCRIPTIONS Continued... MONTH DATE Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start
REGULAR PRESCRIPTIONS Continued... MONTH DATE Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start
REGULAR PRESCRIPTIONS Continued... MONTH DATE Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start
REGULAR PRESCRIPTIONS Continued... MONTH DATE Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start Dose Route Frequency Start
PRN PRESCRIPTIONS Drug Time Dose Route Sig Time Dose Route Sig MIDAZOLAM Dose / Range Route Max Freq Start IM only to be used in the event of a CRISIS (e.g. massive haemorrhage, airway obstruction) Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start
PRN PRESCRIPTIONS Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start
PRN PRESCRIPTIONS Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start
PRN PRESCRIPTIONS Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start Drug Time Dose Route Sig Time Dose Route Sig Dose / Range Route Max Freq Start
SUBCUTANEOUS SYRINGE DRIVER PRESCRIPTION CHART Prescription to be monitored using Checks In Use form 1 Dose 2 Dose (Dr) Started (Dr) Started Stopped Stopped 3 Dose 4 Dose (Dr) Started (Dr) Started Stopped Stopped 5 Dose 6 Dose (Dr) Started (Dr) Started Stopped Stopped 7 Dose 8 Dose (Dr) Started (Dr) Started Stopped Stopped