NAME: AGE/SEX:

UHID: IP No:
ROOM/BED ID:
CONSULTANT:

WEIGHT (KG) BMI (KG/M2)

HEIGHT (M) DIET
BLOOD GROUP ALLERGIES (FOOD/DRUG)
CO-MORBIDITIES
DIAGNOSIS
CARE PLAN (SURGICAL/CONSERVATIVE)
SURGERY/PROCEDURE DATE

Name of Nurse (In capital) Employee ID Initials Recommended administration times

(Guidelines only)
Morning Mane 0800
Night Nocte 1800 or 2000
Twice a day BD 0800 2000
Three times a day TDS 0800 1400 2000
Four times a day QID 0600 1200 1800 2200
th
Regular 6 hourly 6 Hourly 0600 1200 1800 2400
Regular 8 hourly 8th Hourly 0600 1400 2200

MEDICATIONS TAKEN PRIOR TO ADMISSION LEGENDS

DATE
DRUG
NAME
DOSE &
FREQUENCY
ROUTE &
DURATION
Absent Ⓐ On leave Ⓛ
Ⓕ
Not Available-contact
Fasting NA
pharmacy

Ⓦ
Refused – to be Withheld – write
notified ✘ reason
Vomiting Ⓥ Self-administered Ⓢ
Local application LA Per Rectal PR

REGULAR PRESCRIPTIONS
Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

 NAME: AGE/SEX:
UHID: IP No:
ROOM/BED ID:
CONSULTANT:

REGULAR PRESCRIPTIONS
Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-
Doctor's Signature

Signature
Date
Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial

Generic Name

Dose Route Frequency

Stopped by-
Doctor's Signature

Signature
Date
Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial

Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

 NAME: AGE/SEX:
UHID: IP No:
ROOM/BED ID:
CONSULTANT:

REGULAR PRESCRIPTIONS
Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-
Doctor's Signature

Signature
Date
Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial

Generic Name

Dose Route Frequency

Stopped by-
Doctor's Signature

Signature
Date
Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial
Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

Drug Name
Time Initial Time Initial Time Initial Time Initial Time Initial

Generic Name

Dose Route Frequency

Stopped by-

Doctor's Signature
Signature
Date

Date & Time

 NAME: AGE/SEX:
UHID: IP No:
ROOM/BED ID:
CONSULTANT:

SOS & STAT MEDICATION

DOCTOR'S GIVEN CHECKED
DATE DRUG NAME DOSE TIME ROUTE
SIGN BY BY

FLUIDS & INFUSIONS

DOCTOR'S GIVEN CHECKED
DATE FLUIDS, BLOOD, INFUSIONS NAME VOLUME/DOSE START TIME
SIGN BY BY

VERBAL ORDERS (To be Countersigned in 24 hours)

PRESCRIBED DOCTOR'S GIVEN CHECKED
DATE DRUG NAME DOSE FREQUENCY ROUTE BY SIGN BY BY

ADDITIONAL PATIENT NOTES