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Medway School of Pharmacy 2010/11

Adapted from various hospital prescription charts

Maritime Hospitals Trust


INPATIENT PRESCRIPTION CHART
DRUG SENSITIVITY
Hospital: Anson
Ward:

Weight (kg)

Consultant:

Diet:

12345
Surname: Patient
First Name: A
Hospital No:

NKDA
Height (m)

65
Tick if
active
oncology chart

A.Smith

Address:

D.O.B.:

The Copse, Newtown

Gender: Female
OR USE PATIENT LABEL

Patients own medicines

INSTRUCTIONS

- Number of items brought in

ENSURE THAT ALL PATIENTS DETAILS


ARE COMPLETED

Drug

Qty

Suitable
for use?

Y/ N
Y/N
Y/N
Y/N
Y/N
Y/N

Were drugs not suitable for use sent to


Pharmacy?

Y/N
Y/N
Y/N

Patient consent to use medicines on ward or

To Nurses: -

destroy medicines as appropriate


Patient signature:
Date:
By / at discharge were
unused medicines
returned to: (tick box)

To Doctors: 1. Write legibly and avoid abbreviations.


2. Use generic name and metric dose. Write
micrograms and units in full.
3. Order in appropriate section and sign to
legalise prescription.
4. For any changes in the order, new
prescription must be written.
5. Discontinue a drug by entering the stop
date, draw a line through administration
panel, then initial it.
6. Prescriptions for antibiotics must include a
stop date.
7. Always make a relevant entry in drug
sensitivity box e.g. NOT KNOWN, NONE
1. The nurse administering the drug should
initial the appropriate box in the
administration column.
2. In the event of non-administration of a drug,
enter appropriate code (see bottom of
prescription chart) in the appropriate box;
give reason to the doctor and document in
the nursing record.

Patient?
Pharmacy?

ONCE ONLY AND PRE-ANAESTHETIC MEDICATION


Date

Time
prescribed

DRUG
(approved name)

Route

Dose

Doctors
signature

Given
by

Time
given

Pharmacy

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission as
appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes

Medway School of Pharmacy 2010/11

Adapted from various hospital prescription charts

REGULAR PRESCRIPTIONS
Patient Name

A Patient

2010

Month

Year

Hospital Number

October.

Date

Drug Name:
(Generic)
Dose

20mg

0600
0800

Citalopram tab
Route

oral

Additional instructions:

Freq.

Start

Stop

om 24/10/10
sos see drops protocol

Sign Doctor

Date

A.Doctor

24/10/10 A Pharmacist

Pharmacist

Drug Name:
(Generic)
Dose

Route

Freq.

Start

Stop

Additional instructions:
Sign Doctor

Date

Pharmacist

Drug Name:
(Generic)
Dose

Route

Freq.

Start

Stop

Additional instructions:
Sign Doctor

Date

Pharmacist

Drug Name:
(Generic)
Dose

Route

Freq.

Start

Stop

Additional instructions:
Sign Doctor

Date

Pharmacist

Drug Name:
(Generic)
Dose

Route

Freq.

Start

Additional instructions:
Sign Doctor

Date

Pharmacist

Stop

12345

25/
10

26
/20

27
/10

28/
10

29/
10

AN

AN

BN

CN

30/
10

31/
10

1300
1800
2200
0000
0600
0800
1300
1800
2200
0000
0600
0800
1300
1800
2200
0000
0600
0800
1300
1800
2200
0000
0600
0800
1300
1800
2200
0000

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission as
appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes

Medway School of Pharmacy 2010/11

Adapted from various hospital prescription


charts

Medication to be given as required, at the discretion of the


nurse in charge
Name

A Patient

Year

Drug Name:
Dose

1gram
Indication:

Route

oral
Pain

Start

Stop

24/10/10
Max Freq. qds

Sign Doctor

Date

Pharmacist

A.Doctor

24/10/10

APharmacist

Drug Name:
(Generic)
Dose
Indication:
Sign Doctor

Indication:
Sign Doctor

Route

Date

Start

Stop

Max Freq.
Pharmacist

Indication:
Sign Doctor

Route

Date

Start

Stop

Max Freq.
Pharmacist

Indication:
Sign Doctor

Route

Date

Start

Stop

Max Freq.
Pharmacist

Indication:
Sign Doctor

Time
Route
Dose
Given
by

Time
Route
Dose
Given
by

Time
Route
Dose
Given
by

Time
Route
Dose
Given
by
Date

Route

Date

Start

Stop

Max Freq.
Pharmacist

Drug Name:
(Generic)
Dose

12345

Date

Drug Name:
(Generic)
Dose

Hosp.No.

Date

Drug Name:
(Generic)
Dose

October

Date

Drug Name:
(Generic)
Dose

Month

Date

Paraceetamol

(Generic)

2010

Time
Route
Dose
Given
by
Date

Route

Date

Start

Stop

Max Freq.
Pharmacist

Time
Route
Dose
Given
by

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission
as appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes

Medway School of Pharmacy 2010/11

Adapted from various hospital prescription


charts

Complex and Variable Dose Prescriptions


Name

A Patient

Year

Drug Name:
(Generic)

Citalopram drops

2010

Month

October

Hosp.No.

12345

Date

Time

Observation

Dose

29/10

8.30

Accepted
in orange
juice

10
AP
drops

Signature

Given by

AN

Date

Time

Dose

Given by

Dose and instructions:


(Specify monitoring variables, frequency or any
protocol)

When patient refuses tablets


give 20mg (10 drops) mix into
fruit juice

Route:

Oral

Pharmacy

Start date and time

24/10/10 at 8.00
Sign Doctor

A Doctor

CANCEL
(date and sign)

Drug Name:
(Generic)

Observation

Signature

Dose and instructions:


(Specify monitoring variables, frequency or any
protocol)

Route

Pharmacy

Start date and time

Sign Doctor

CANCEL
(date and sign)

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission
as appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes

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