Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download WA Variable Dose Chart - Department of Health WA
Document related concepts
no text concepts found
Transcript
AFFIX PATIENT IDENTIFICATION LABEL HERE & OVERLEAF Attach ADR Sticker ALLERGIES & ADVERSE REACTIONS (ADR) Nil known Unknown (tick appropriate box or complete details below) Drug (or other) Reaction/Date Initials UR No: Family Name: NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT Given Names: Address: DOB: Sign ........................................ Print ......................................... Date ................. Medication (Print Generic Name) Route .......................................................................... Height (cm) ......................................... VARIABLE DOSE Chart No. of MEDICATIONS WITH VARIABLE DOSAGE Indication/Directions Time of Dose Pharmacy Use Dose Drug Level /Result Time Level Taken This medication continued on new chart Yes No Nurse/Midwife Initials Prescriber Name Signature 1st 2nd Time Given Clinical Pharmacist Review OR Variable Dose Chart No. NIMC No. Medication (Print Generic Name) Route Indication/Directions Desired Result Time of Dose Dose Drug Level /Result Time Level Taken Prescriber Name Signature Nurse/Midwife Initials 1st 2nd Time Given Clinical Pharmacist Review MR Version No: Date Pharmacy Use VARIABLE DOSE CHART Desired Result Date F Patient Weight (kg) ............................ Ward/Unit: Consultant: M 1st Prescriber to Print Patient Name and Check Label Correct: Hospital: Health Service Logo Sex This medication continued on new chart Yes No NIMC No. OR Variable Dose Chart No. AFFIX PATIENT IDENTIFICATION LABEL HERE & OVERLEAF MEDICATIONS WITH VARIABLE DOSAGE UR No: Family Name: NOT A VALID PRESCRIPTION UNLESS IDENTIFIERS PRESENT Given Names: Attach ADR Sticker Address: See front page for details DOB: Sex M F 1st Prescriber to Print Patient Name and Check Label Correct:............................................ Year 20 MEDICATIONS WITH VARIABLE DOSAGE Medication (Print Generic Name) Route Indication/Directions Desired Result Date Time of Dose Pharmacy Use Dose Drug Level /Result Time Level Taken This medication continued on new chart Yes No Nurse/Midwife Initials Prescriber Name Signature 1st 2nd Time Given Clinical Pharmacist Review OR Variable Dose Chart No. NIMC No. Medication (Print Generic Name) Route Indication/Directions Desired Result Date Time of Dose Pharmacy Use Dose Drug Level /Result Time Level Taken This medication continued on new chart Yes No Prescriber Name NIMC No. Signature Nurse/Midwife Initials 1st 2nd Time Given OR Variable Dose Chart No. Clinical Pharmacist Review
Related documents