Attach ADR Sticker
ALLERGIES & ADVERSE DRUG REACTIONS (ADR)
Known
Unknown
RECOMMENDED
ADMINISTRATION TIMES
AFFIX PATIENT IDENTIFICATION LABEL HERE AND OVERLEAF
Nil
(tick appropriate box or fill in details below)
URN:
Family Name:
GUIDELINES ONLY
Morning
Night
Drug (or other)
Reaction/Type/Date
Initials
Given Names:
Address:
Date of Birth:
SR = Sustained, modified or
controlled release formulation.
NOT A VALID PRESCRIPTION
UNLESS IDENTIFIERS PRESENT
Sex:
M
Twice a day
0800
Nocte
1800 or 2000
BD
0800
2000
TDS
0800
1400
2000
6 hrly
0600
1200
1800
2400
Regular
8 hrly
0600
1400
2200
8
hourly
Four times a
day
QID
0600
1200
1800
2200
Three times a
day
Regular 6
hourly
F
Mane
Weight (kg):
Date weighed: ………
DATE & MONTH
PRESCRIBER MUST ENTER administration times
Medicine & Strength (Print Generic Name)
Date
Route
Dose
Frequency & NOW enter times
NOT A VALID ORDER UNLESS LEGIBLE
DO NOT WRITE IN THIS BINDING MARGIN
Pharmacy/Additional Information
Prescriber Signature
YEAR 20……………
DATE & MONTH
PRESCRIBER MUST ENTER administration times
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Frequency & NOW enter times
Pharmacy/Additional Information
Print Your Name
Contact/Pager
Prescriber Signature
Print Your Name
Date
Medicine & Strength (Print Generic Name)
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Route
Dose
Frequency & NOW enter times
Pharmacy/Additional Information
Prescriber Signature
Frequency & NOW enter times
Contact/Pager
Prescriber Signature
Print Your Name
Date
Medicine & Strength (Print Generic Name)
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Route
Dose
Frequency & NOW enter times
Frequency & NOW enter times
Print Your Name
Contact/Pager
Prescriber Signature
Print Your Name
Date
Medicine & Strength (Print Generic Name)
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Route
Dose
Frequency & NOW enter times
Pharmacy/Additional Information
Prescriber Signature
Pharmacy/Additional Information
Print Your Name
Contact/Pager
Prescriber Signature
Print Your Name
Medicine & Strength (Print Generic Name)
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Route
Dose
Frequency & NOW enter times
Pharmacy/Additional Information
Contact/Pager
Frequency & NOW enter times
Pharmacy/Additional Information
Print Your Name
Contact/Pager
Prescriber Signature
Print Your Name
Date
Medicine & Strength (Print Generic Name)
Date
Medicine & Strength (Print Generic Name)
Route
Dose
Route
Dose
Frequency & NOW enter times
Pharmacy/Additional Information
Prescriber Signature
Contact/Pager
Frequency & NOW enter times
Date
Prescriber Signature
Contact/Pager
Pharmacy/Additional Information
Pharmacy/Additional Information
Prescriber Signature
Contact/Pager
Pharmacy/Additional Information
Print Your Name
Contact/Pager
Frequency & NOW enter times
Pharmacy/Additional Information
Print Your Name
Contact/Pager
Codes MUST be circled
Absent
Fasting
Refused - notify prescriber
Vomiting
On leave
Not available-enter
reason in clinical record
Witheld-enter reason in
clinical record
Self aministered
Parent/Carer administered
Sign …………………...….. Print ………………………..……. Date …………….…..
YEAR 20……………
If scored tablet, then half can be
given.
Dose must be swallowed without
crushing
First Prescriber to print patient name and check label correct:
REGULAR MEDICATIONS
Tick if
Slow
Release
REASON FOR NOT ADMINISTERING
Prescriber Signature
Print Your Name
Contact/Pager
A
F
R
V
L
N
W
S
P
AFFIX PATIENT IDENTIFICATION LABEL HERE AND OVERLEAF
URN:
Family Name:
Address:
AS REQUIRED
"PRN"
MEDICATIONS
NOT A VALID
Given Names:
PRESCRIPTION UNLESS
IDENTIFIERS PRESENT
Date of Birth:
Sex:
M
NAME OF GP
Place Photo Here
Weight (kg): ……………..
Date Weighed: …………..…..
F
CONTACT NUMBER OF
GP
First Prescriber to print patient name and check label correct:
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Date
Time
Dose
Route
Contact/Pager
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
AFFIX PATIENT IDENTIFICATION LABEL HERE AND OVERLEAF
Sign
URN:
Date
Family Name:
NOT A VALID
PRESCRIPTION UNLESS
IDENTIFIERS PRESENT
Time
Dr to Confirm Child's Name
Dose
Address:
Route
Prescriber Signature Print Your Name
Contact/Pager
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Date of Birth:
Sign
Route
Contact/Pager
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Time
Sign
Date
Time
Dose
Route
Prescriber Signature Print Your Name
Contact/Pager
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Sign
Date
Time
Dose
Route
Prescriber Signature Print Your Name
Contact/Pager
Date
Medication & Strength (Print Generic Name)
Route
DOSE
Hourly Frequency
Max Dose/24 hrs
PRN
Pharmacy Additional Information
Sign
Date
Time
Dose
Route
Prescriber Signature Print Your Name
Contact/Pager
F
Medication
(Print Generic Name)
Route
DOSE
Prescriber
Date/Time
to be given Signature
Print your
Name
DOSE Calc
eg. mg/kg
Per Dose
Given by
Date/Time
by
Pharm
Date
Route
Contact/Pager
Date
Prescribed
Sign
Dose
Prescriber Signature Print Your Name
M
MEDICATION CHART NO. ………………………. of ………………………..
ONCE ONLY MEDICINES
PAEDIATRIC
Time
Dose
Prescriber Signature Print Your Name
Sex:
Date
Sign
LONG STAY MEDICATION CHART
NOT VALID ORDER UNLESS LEGIBLE
Prescriber Signature Print Your Name
RECORD OF
ADMINISTRATION
TELEPHONE ORDERS (To be signed within 24 hours of order)
Date
Time
Medication
Generic Name)
(Print
Route
Dose
Frequency
Nurse Initials
1
2
Dr Name
Dr Sign
Date
Time Given Time Given Time Given
By
By
By