Sheridan College Hospital
Medication Administration Record
Patient Addressograph:
Name:
DOB:
MRN
Pt Name:
Diagnosis:
Allergies
PMHx/SHx:
Special Instructions:
Routine Medications:
Date Ordered:
Transcribed by:
Verified by:
Date Ordered:
Transcribed by:
Verified by:
Date Ordered:
Transcribed by:
Verified by:
Date Ordered:
Transcribed by:
Verified by:
Date Ordered:
Transcribed by:
Verified by:
Date Ordered:
Transcribed by:
Verified by:
Dose
Medication
Route
MM-YYYY:
Date (DD)
Frequency
Time
Patient Addressograph:
Name:
DOB:
MRN:
Single Orders:
Date Ordered:
15-Jan-20
MM-YYYY:
Dose
Medication
Route
Frequency
To be Administered:
Date
Time Initials:
Date
Administered:
Initials:
Time
Transcribed by:
T.L.
Verified by:
A.B.
Date Ordered:
Transcribed by:
Verified by:
PRN Medications:
Date Ordered:
Dose
MM-YYYY:
Medication
Route
Frequency
Transcribed by:
Date
Administered:
Time
Administered:
Verified by:
Date Ordered:
Transcribed by:
Time
Administered:
Verified by:
Date Ordered:
Time
Administered:
Transcribed by:
Verified by:
Health Care Provider
Written Name:
Thomas Lester
Vanessa Hunt
Signature:
T.Lester
V. Hunt
Initials:
Designation:
T.L.
RN
VH
RPN