Download Adult Revolving Fund Pharmacy Prescription Form

Adult Revolving Fund Pharmacy Prescription Form
AMPATH#____patient.medical_record_number Date____encounter.encounter_id
1901Drug Name
(tick)1895
Non-ARV Medication Prescription Form
Indication (please tick)
Sig (Qty per pack)
6042
1896
Analgesic
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Headache 620Fever 5945Pain 7032 1 TDS 1889 x 3days
Ibuprofen 400mg 912 (43)
Inflammation
(9)
 Paracetamol 500mg
2 TDS x 3days(18)
Headache620Fever5945Pain7032
89 (44)
Anti-Infective
Amoxicillin 500mg
Pneumonia 43 Resp inf 999 Sinusitis 1 TDS x 7days(21)
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265 (45)
222 Strep throat 150Other 5622
Erythromycin 400mg
Pneumonia Resp inf SinusitisStrep
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1 TDS x 7days(21)
272 (46)
throatOther
GI Infection UTI 55 gonorrhea893
1 BD 1888 x
Ciprofloxacin 500mg
/chlamydia 6247
5days(10)
 740 (47)
Typhoid 141
1 BD x 14days(28)
Skin infection 79 Pneumonia
43Resp Inf 999Sinusitis
1BD x 7days(14)
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222Chlamydia 6247/PID 902→Add
Doxycycline 100mg
quinolone
95 (48)
GI Infection UTI
1 BD x 5days(10)
Typhoid
1 BD x 14days(28)
 Amoxicillin/Clavulanic
Pneumonia Resp inf
1 BD x 7 days (14)
SinusitisStrep throatOther
acid 625mg 450 (57)
Coartem (AL) 6282 (67,
Malaria123
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4 BD x 3 days (24)
68, 69)
Mebendazole 100mg
Worms199
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1 BD x 3 days (6)
244 (49)
Albendazole 400mg
Worms199 (pregnant patients)
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1 OD x 1 (1)
941 (50)
 Metronidazole 200mg
Amoebiasis 124Giardia
2 TDS x 7days (42)
237 (51)
713Anaerobe Trich
Apply to affected area
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Local
skin
infection
Dermoguard cream 2253
# of
packs
1 2 3
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Anti-inflammatory Asthma 5
Prednisolone 5mg tab
 765 (52)
PCP with low O2 Sat (<90%)
Cardiovascular Medications
 Enalapril 10mg
CCF 1456 HTN 903Kidney Disease
1242 (53)
1886 Diabetes 175
 HCTZ 50mg 1243 (54) HTN
Gastrointestinal
 Antacid tab 944
Heartburn 111 GERD 1293
 Loperamide 2mg
ARV diarrhea Prolonged Diarrhea
429 (55)
5018
 Omeprazole 20mg
Heartburn GERD
1244 (56)
Vitamin Supplementation
 FerrousSO4 (60mg Fe) Low MCV Anemia
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256 (58)
 Folic acid 257 (70)
 Multivitamin tab 461
 Other 5622
 Other 5622
High MCV Anemia Pregnancy 44
Nutritional supplement
1 OD PRN x7days(7)
2 puffs QID PRN(1)
1890
4 BD x 3days(24)
8 BD x 5days, 8 OD
x 5 days, then 4 OD
x 11days (164)
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1-2 prn (6)
1 OD x 7 days (7)
1 TDS x 30 days
(90)
1 OD x 30 days (30)
1OD x 30days (30)
Ciprofloxacin 500mg
 Amoxicillin/Clavulanic
acid 625mg
 Coartem (AL)
 Mebendazole 100mg
 Albendazole 400mg
 Metronidazole 200mg
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Dermoguard cream
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Non-ARV Medication Prescription Form
Indication (please tick)
# of
packs
1 2 3
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Pneumonia Resp inf SinusitisStrep 1 TDS x 7days(21)
throatOther
Pneumonia Resp inf SinusitisStrep
1 TDS x 7days(21)
throatOther
GI Infection UTI gonorrhea/chlamydia 1 BD x 5days(10)
Typhoid
1 BD x 14days(28)
Skin infection Pneumonia Resp Inf
1BD x 7days(14)
SinusitisChlamydia/PID→Add quinolone
GI Infection UTI
1 BD x 5days(10)
Typhoid
1 BD x 14days(28)
Pneumonia Resp inf
1 BD x 7 days (14)
SinusitisStrep throatOther
Malaria
4 BD x 3 days (24)
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Worms
1 BD x 3 days (6)
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1 OD x 1 (1)
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2 TDS x 7days (42)
Apply to affected area
BD
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Worms (pregnant patients)
AmoebiasisGiardiaAnaerobeTrich
Local skin infection
PCP with low O2 Sat (<90%)
Cardiovascular Medications
 Enalapril 10mg
CCFHTNKidney DiseaseDiabetes
 HCTZ 50mg
HTN
Gastrointestinal
 Antacid tab
HeartburnGERD
 Loperamide 2mg
ARV diarrhea Prolonged Diarrhea
 Omeprazole 20mg
Heartburn GERD
Vitamin Supplementation
 FerrousSO4(60mg Fe) Low MCV Anemia
 Folic acid
 Multivitamin tab
 Other
 Other
Sig (Qty per pack)
HeadacheFeverPainInflammation 1 TDS x 3days (9)
HeadacheFeverPain
2 TDS x 3days(18)
Antihistamine/Allergy/Asthma/Steroid
 Chlorpheniramine
AllergyItchingRash Folliculitis
 Salbutamol inh
AsthmaDifficulty Breathing
Anti-inflammatoryAsthma
 Prednisolone 5mg tab
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2 TDS PRNx5days(30)
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 Doxycycline 100mg

½ OD x 30 days (30)
Analgesic
 Ibuprofen 400mg
 Paracetamol 500mg
Anti-Infective
 Erythromycin 400mg

1 OD x 30 days (30)
Drug Name (tick)
 Amoxicillin 500mg
BD
Antihistamine/Allergy/Asthma/Steroid
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Allergy 142Itching 879Rash
Chlorpheniramine 913
512Folliculitis 842
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Asthma 5Difficulty Breathing 7225
Salbutamol inh 798
Price
(Kshs)
Name___________patient.given_name, patient.middle_name, patient.family_name
Gender: patient.sex Male Female
Prescriber: Clinical Officer Express Care NurseConsultant encounter.provider_id Prescriber Code: _
Prescriber Signature: _______________________ Pharmacy Initials Entered by: _____Dispensed by: ____
High MCV Anemia Pregnancy
Nutritional supplement
1 OD PRN x7days(7)
2 puffs QID PRN(1)
4 BD x 3days(24)
8 BD x 5days, 8 OD
x 5 days, then 4 OD
x 11days (164)
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1 OD x 30 days (30)
½ OD x 30 days (30)
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2 TDS PRNx5days(30)
1-2 prn (6)
1 OD x 7 days (7)
1 TDS x 30 days
(90)
1 OD x 30 days (30)
1OD x 30days (30)
Receipt #: ___________________
Adult Revolving Fund Pharmacy Prescription Form
AMPATH#____________________________ Date______________
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Price
(Kshs)
Name_____________________________________________________________________________
Gender: Male Female
Prescriber: Clinical Officer Express Care NurseConsultant
Prescriber Code: ________________
Prescriber Signature: _______________________ Pharmacy Initials Entered by: _____Dispensed by: ____
Receipt #: ___________________