commmunity care medication chart
DESCRIPTION
Generic design community care medication chartTRANSCRIPT
OLD
OLD
02/13
© COPYRIGHT COMPACT BUSINESS SYSTEMS PTY LTD 2010
Co
mm
un
ity
Me
dic
ati
on
Re
co
rd
Crush
Thickened Fluids
Observe Swallowing
Encouragement NeededWhole
Peg
Other
ALLERGIES & ADVERSE REACTIONS (ADR)
PERSONAL PARTICULARS
Client’s Surname
Given Name: Client Preferred Name:
Date of Birth: Client No.
7 RIGHTS’ OF MEDICATION ASSISTANCE
Checkthese
5 rights3 times
1. Right Method - Obtain details from Care Plan eg. breakin half, crush, put into yogurt etc.
2. Right Person3. Right Drug or medication4. Right Dose5. Right Time / Date / Day6. Right Route (which way is medication
given, orally, topically etc)7. Write it Down - Staff sign when medication has been
administered.
DOSE OMITTED CODES
Medications not able to be given should berecorded in Client’s Notes
Absent
Adjusted Administration
Fasting
Hospital
On Leave
A
Refused - Notify Dr
Withheld - Enter reason inClinical Record
Withheld - PendingResults
Self Administering
Vomitting
O
R
S
V
Unusable (eg. dropped) UNo Stock N
A/T
N/R
W/R
F
H
L
W
Omitted
Not Required
( ) DrugAlert
( ) No Known Drug Alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/ /Date
/ /Date
Enter Details:
DR UG ALE R TLAB E L
ATTAC H ALE R T LAB E L HE R E ANDWHE R E INDIC ATE D INS IDE C HAR T
Signature
Signature
Pharmaceutical Benefits Entitlement Number
VALID TO
Medicare Number
/ /
VALID TO
/ /
ENTITLEMENT NUMBERS
REFER TO CARE PLAN ROUTINE
PHARMACY PARTICULARS
VACCINATIONS
Influenza Vac c ine - Date Las t G iven: / /
P neumococcal Vaccine - Date Las t G iven: / /
Tetanus Vac c ine - Date Las t G iven: / /
Hep A/ B Vac c ine - Date Las t G iven: / /
- Date Las t G iven: / /
- Date Las t G iven: / /
- Date Las t G iven: / /
S cheduled C hildhood Vaccine UTD Yes No
Phone No.
PRESCRIBER PARTICULARS
Phone No.
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Month: 20
Client’s Name D.O.B.
REGULAR MEDICATION ORDERS Times
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
Apply Medical Director Medication Adhesive Label
ClientNo.
ADR ALERT
Yes No (Circle)
IND
IVID
UA
L M
ED
ICA
TIO
N O
RD
ER
S 1
-8PA
CK
ED
ME
DIC
AT
ION
S SIGN IN THIS PANEL FOR ALLPACKED MEDICATION
SIGN FOR INDIVIDUALMEDICATION IN THE PANELS
BELOW
PAC
KE
D
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 1
Page 2
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 3
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 4
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 5
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 6
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 7
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 8
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 9
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 10
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
RE
GU
LAR
ME
DIC
AT
ION
S 1
Page 11
FOLD
ON
TH
IS L
INE
TO
US
E A
S A
12
MO
NT
H C
HA
RT
R egular Medic ation Adminis tration
MEDICATION NOTES
ADR ALERT
Yes No (Circle)
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 12
Client’s Name D.O.B.
REGULAR MEDICATION ORDERS 9 TO 17 Time
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
Apply Medical Director Medication Adhesive Label
1 2 3 4 5 6 157 8 9 10 11 12 13 14
ADR ALERT
Yes No (Circle)Month: 20
ClientNo.
Page 13
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 14
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 15
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 16
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 17
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 18
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 19
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 20
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 21
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 22
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
RE
GU
LAR
ME
DIC
AT
ION
S 2
- (
SH
OR
T T
ER
M &
VE
RB
AL
OR
DE
RS
BA
CK
PA
GE
)
Page 23 R egular Medic ation Adminis tration
MEDICATION NOTES
ADR ALERT
Yes No (Circle)
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SHORT TERM MEDICATION ORDERS
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
PRN (When Required) Medication Orders Date Time Qty. S ig. Date Time Qty. S ig.R eas on / Ins truc tionsPRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
ADR ALERT
Yes No (Circle)
Client’s Name D.O.B.
Month: 20
ClientNo.
Date Date Date Date Date DateS ig. S ig. S ig. S ig. S ig. S ig.Time Time Time Time Time TimeQty. Qty. Qty. Qty. Qty. Qty.
NOTE: To Cancel - Draw diagonal line through entry after 24 hours. If Doctor is usingCompact confirmation labels, insert label number in column provided
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
ADMINISTRATION
VERBAL / TELEPHONE ORDERS - VALID FOR 24 HOURS ONLY
NURSE INITIATED MEDICATION ORDERS
Nurse Initiated Medication
R.N. Signature
Doctors Signature
Start Date
Stop Date
Dose
Reason
Route
Frequency
Nurse Initiated Medication
R.N. Signature
Doctors Signature
Start Date
Stop Date
Dose
Route
Frequency
Nurse Initiated Medication
R.N. Signature
Doctors Signature
Start Date
Stop Date
Dose
Route
Frequency
Date DateTime TimeQty. Qty.Sign. Sign.
FO
FO
1.00 . . . . . . . . . . . . . . . . . . . . 01002.00 . . . . . . . . . . . . . . . . . . . . 02003.00 . . . . . . . . . . . . . . . . . . . . 03004.00 . . . . . . . . . . . . . . . . . . . . 04005.00 . . . . . . . . . . . . . . . . . . . . 05006.00 . . . . . . . . . . . . . . . . . . . . 06007.00 . . . . . . . . . . . . . . . . . . . . 07008.00 . . . . . . . . . . . . . . . . . . . . 08009.00 . . . . . . . . . . . . . . . . . . . . 0900
10.00 . . . . . . . . . . . . . . . . . . . . 100011.00 . . . . . . . . . . . . . . . . . . . . 110012.00 . . . . . . . . . . . . . . . . . . . . 1200
24 HOUR CLOCKAM - Morning
1.00 . . . . . . . . . . . . . . . . . . . . 13002.00 . . . . . . . . . . . . . . . . . . . . 14003.00 . . . . . . . . . . . . . . . . . . . . 15004.00 . . . . . . . . . . . . . . . . . . . . 16005.00 . . . . . . . . . . . . . . . . . . . . 17006.00 . . . . . . . . . . . . . . . . . . . . 18007.00 . . . . . . . . . . . . . . . . . . . . 19008.00 . . . . . . . . . . . . . . . . . . . . 20009.00 . . . . . . . . . . . . . . . . . . . . 2100
10.00 . . . . . . . . . . . . . . . . . . . . 220011.00 . . . . . . . . . . . . . . . . . . . . 230012.00 . . . . . . . . . . . . . . . . . . . . 2400
PM - Afternoon
DOSE FREQUENCY OR TIMING
(in the) morning morning, mane
(at) midday midday
(at) night night, nocte
twice a day bd
three times a day tds
four times a day qid
every 4 hours every 4 hrs, 4 hourly, 4 hrly
every 6 hours every 6 hrs, 6 hourly, 6 hrly
every 8 hours every 8 hrs, 8 hourly, 8 hrly
once a week once a week and specify the day in full,eg. once a week on Tuesdays
three times a week three times a week and specify the exact days in full, eg. three times a week on Mondays, Wednesdays and Saturdays
when required prn
immediately stat
before food before food
after food after food
with food with food
ROUTE OF ADMINISTRATIONepidural epiduralinhale, inhalation inhale, inhalationintraarticular intraarticularintramuscular IMintrathecal intrathecalintranasal intranasalintravenous IVirrigation irrigationleft leftnebulised NEBnaso-gastric NGoral POpercutaneous enteral gastrostomy PEGper vagina PVper rectum PRperipherally inserted central catheter PICCright rightsubcutaneous subcutsublingual sublingtopical topical
UNITS OF MEASURE AND CONCENTRATIONgram(s) gInternational unit(s) international unit(s)unit(s) unit(s)litre(s) Lmilligram(s) mgmillilitre(s) mLmicrogram(s) microgram, microgpercentage %millimole mmol
DOSE FORMScapsule capcream creamear drops ear dropsear ointment ear ointmenteye drops eye dropseye ointment eye ointmentinjection inj
metered dose inhalermetered dose inhaler, inhaler, MDI
mixture mixtureointment ointment, ointpessary pesspowder powdersuppository supptablet tablet, tabpatient controlled analgesia PCA
Recommendations for Terminology, Abbreviations and Symbols used in thePrescribing and Administration of Medicines
Supplied by: Australian Commission on Safety and Quality in Health Carewww.safetyandquality.gov.au
Re-Order Ref. LTCC-01Long Term Community Medication Chart
ALL STATESPhone: 1800 777 508Fax: (07) 3376 2001
Email: [email protected]: www.compact.com.au
NEW ZEALANDInternational Freecall 0800 445 447
Fax: 61 7 3376 2001
DOSE OMITTED CODES
Medications not able to be given should berecorded in Client’s Notes
Absent
Adjusted Administration
Fasting
Hospital
On Leave
A
Refused - Notify Dr
Withheld - Enter reason inClinical Record
Withheld - PendingResults
Self Administering
Vomitting
O
R
S
V
Unusable (eg. dropped) UNo Stock N
A/T
N/R
W/R
F
H
L
W
Omitted
Not Required
© Compact Business Systems Pty Ltd 2010
C opyright Notic e: This medic ation c hart and all forms in it are protected by Australian and International Copyright Laws. No part ofthem may be reproduced, transmitted or manipulated in any form or by any means electronic, digital or otherwise without obtaining
prior written permission from Compact Business Systems Pty Ltd. This includes photocopying, scanning and posting the medicationchart or any part of it online.
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