University Hospitals of Leicester NHS Trust Chart

A D U LT I N PAT I E N T M E D I C AT I O N
A D M I N I S T R AT I O N R E C O R D
Chart
of
Consultant
PAT I E N T D E TA I L S
University Hospitals of Leicester

NHS Trust
Ward
BSA(m2)
Site
Wt (kg)
Ht
D E TA I L S O F S U P P L E M E N TA R Y C H A R T S I N U S E
Anticoagulant
Diabetes
Supplementary infusion chart
Other (please specify)
Chemotherapy
Syringe driver
Gentamicin/Tobramycin
Haemodialysis
PRESCRIPTION FOR ONCE-ONLY MEDICATION / PRE-ANAESTHETIC / ANTIMICROBIAL PROPHYLAXIS

Date Time to
be given
1
2
3
4
5
Medicine
(approved name)
Dose
Route
Prescribers signature
and name
Bleep Date Time Given

No. given given
by
DRAFT
6
7
8
9
10
11
12
Check
Pre-admission
Drug history check
Source:
Rewritten drug chart checked
Allergy check
Patients own medicines
Self-administration
Compliance aid
Patient discharge
TTO written
Signed
TTO supplied
Counselling
Initial
Date
Initial
Date
MEDICINE PRIOR TO ADMISSION NOT PRESCRIBED

Medicine
Dosage Freq.
Reason
D I S C H A R G E I N F O R M AT I O N
(Causon7/09)6090623KR
MEDICINES MANAGEMENT CHECKLIST
I V C A N N U L AT I O N
Intravenous Cannulation Aseptic Technique Used
INTRAVENOUS CANNULA 1 Indication
Removal Date
Date Inserted
Date Inserted
Removal Date
Date Inserted
Removal Date
Inserters Name/Signature/Bleep
Insertion Site
Insertion Site
Insertion Site
Date
Phlebitis
Score Score
0-5
Signature
Date
Phlebitis
Score Score
0-5
Signature
Date
Phlebitis
Score Score
0-5
Signature
Removal Date
Date Inserted
Insertion Site
Date
Phlebitis
Score Score
0-5
Signature
Date Inserted
Removal Date
Date Inserted
DRAFT
Removal Date
Insertion Site
Insertion Site
Date
Phlebitis
Score Score
0-5
Signature
Date
Phlebitis
Score Score
0-5
Signature
OXYGEN THERAPY
13 DRUG
OXYGEN
88 - 92% 94 - 98% Other

PRN / Continuous
(refer to O2 guideline)
Tick here if saturation
not indicated
DATE
CIRCLE TARGET OXYGEN SATURATION
OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED
DATE ADMINISTERED
09
14
18
Signature:
22
Date:
Print name:
14 DRUG
OXYGEN
88 - 92% 94 - 98% Other

PRN / Continuous
(refer to O2 guideline)
Tick here if saturation
not indicated
Signature:
Date:
DATE
CIRCLE TARGET OXYGEN SATURATION
OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED
DATE ADMINISTERED
09
14
18
22
Print name:
CODE FOR DRUG OMISSIONS
When drug is not administered, record the appropriate number in the box, circle and sign. Doctors to be informed at discretion of nurse.
REGULAR ANTIMICROBIAL THERAPY

MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
ENTER DOSE AGAINST TIME REQUIRED SWITCH FROM IV ROUTE TO ORAL AS SOON AS POSSIBLE - MAX 48HRS
15 Date
Route
"
MEDICINE (approved name)
COURSE LENGTH VERIFICATION No.
INDICATION
SPECIAL INSTRUCTIONS
"
Specify time
required !
Dose
!
Sign
STOP
after
Morning
5 days
Midday
(unless
Teatime
otherwise
stated)
Bedtime
16 Date
Route
"
"
Specify time
required !
Dose
!
Sign
DRAFT
Date
5 days
(unless
Teatime
otherwise
Bedtime
stated)
"
INDICATION
"
Specify time
required !
Dose
!
Sign
Date
PRESCRIBERS
PHARMACIST
SIGNATURE & NAME
SUPPLY
Bleep no.
Dose change !
DATE
STOP
after
Morning
5 days
Midday
(unless
Teatime
otherwise
stated)
Bedtime
Route
Bleep no.
STOP
Midday
18 Date
SUPPLY
after
Morning
Route
PRESCRIBERS
PHARMACIST
SIGNATURE & NAME
INDICATION
Dose change !
DATE
17 Date
SUPPLY
Bleep no.
Dose change !
DATE
PRESCRIBERS
PHARMACIST
SIGNATURE & NAME
"
INDICATION
"
Specify time
required !
DATE
Dose
!
Sign
Date
SUPPLY
Bleep no.
Dose change !
STOP
after
Morning
5 days
Midday
(unless
Teatime
otherwise
stated)
Bedtime
1 Declined
7 No access (NG PEG/IV)
PRESCRIBERS
PHARMACIST
SIGNATURE & NAME
2 Vomiting/Nausea
8 Unable to take
3 Nil by mouth
9 Patient not on ward
4 Not required
10 Inappropriate/unclear prescription
5 Drug not on ward

11 Awaiting medical advice
6 Omission - other treatment in progress

12 Self-administration
I V C A N N U L AT I O N / O X Y G E N T H E R A P Y / R E G U L A R A N T I M I C R O B I A L T H E R A P Y
Date
YEAR
REGULAR MEDICINES
YEAR
ENTER DOSE AGAINST TIME REQUIRED

DATE
19 MRSA DECOLONISATION
PROPHYLAXIS REGIMEN
Antibacterial Wash Apply directly onto skin
using a cloth ONCE daily

instead of soap
Brand:
Use to wash hair TWICE A WEEK

For high risk patients only
Apply to both
nostrils
THREE/..
times a day
Nasal Antibiotic Cream

Brand:
Prescribers signature:
Dr D Jenkins
20
PRESCRIBERS SIGNATURE & NAME
Date "
DALTEPARIN
Dose
!
DRAFT
Route "
Sign
Date
Dose change !
Bleep No PHARMACIST
SC
INDICATION
FOR THROMBOPROPHYLAXIS
ONLY
INDICATION
SUPPLY
If for treatment prescribe in Regular Medicine
Teatime
21 MEDICINE (approved name)
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
Bleep No. PHARMACIST
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
REGULAR MEDICINES
YEAR

DATE
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Dose change !
Route
Sign
Dose
Date
Morning
SUPPLY POD
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
1 Declined
2 Vomiting/Nausea
8 Unable to take
3 Nil by mouth
4 Not required
5 Drug not on ward


REGULAR MEDICINES
DRAFT
Date
Enter Dose
against Time
REGULAR MEDICINES
YEAR

DATE
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
Date
Morning
INDICATION
DRAFT
SUPPLY POD
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
REGULAR MEDICINES
YEAR

DATE
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Dose change !
Route
Sign
Dose
Date
Morning
SUPPLY POD
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
1 Declined
2 Vomiting/Nausea
8 Unable to take
3 Nil by mouth
4 Not required
5 Drug not on ward


REGULAR MEDICINES
DRAFT
Date
Enter Dose
against Time
REGULAR MEDICINES
YEAR

DATE
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
Date
Morning
INDICATION
DRAFT
SUPPLY POD
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
INDICATION
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
REGULAR MEDICINES
YEAR

DATE
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Dose change !
Route
Sign
Dose
Date
Morning
SUPPLY POD
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
INDICATION
Date
Dose change !
Route
Sign
Enter Dose
against Time
Dose
SUPPLY POD
Date
Morning
Midday
Teatime
Bedtime
1 Declined
2 Vomiting/Nausea
8 Unable to take
3 Nil by mouth
4 Not required
5 Drug not on ward


REGULAR MEDICINES
DRAFT
Date
Enter Dose
against Time
AS REQUIRED MEDICINES
43 MEDICINE
DATE
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
BLEEP No. PHARM. SUPPLY
SIGN
44 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
45 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DRAFT
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
46 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
47 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
48 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
49 MEDICINE
DATE
GIVEN
DATE
DOSE
ROUTE
TIME
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
DRUG ALLERGIES (MUST BE COMPLETED)

Medicine
Reaction
Patients name
No known allergies
Signature
S No.
Designation
Date
Date of birth
50 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
51 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
52 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DRAFT
DOSE
INDICATION
MAX FREQUENCY
SIGN
53 MEDICINE
DATE
ROUTE
GIVEN
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
54 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
55 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
GIVEN
56 MEDICINE
DATE
DATE
DOSE
TIME
ROUTE
DOSE
INDICATION
MAX FREQUENCY
ROUTE
SIGN
1 Declined

2 Vomiting/Nausea
8 Unable to take
3 Nil by mouth
GIVEN
4 Not required
5 Drug not on ward


Date
Type/Strength
Infusion Fluid
Volume
Medicine
Additions to Infusion
Dose
Route
PA R E N T E R A L I N F U S I O N S
DRAFT
Time to Prescriber
run or
ml/hr
Fluid
Batch
No.
Start
Time
Given
by
Checked
by
Signatures

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A D U LT I N PAT I E N T M E D I C AT I O N

University Hospitals of Leicester

PRESCRIPTION FOR ONCE-ONLY MEDICATION / PRE-ANAESTHETIC / ANTIMICROBIAL PROPHYLAXIS

Bleep Date Time Given

MEDICINE PRIOR TO ADMISSION NOT PRESCRIBED

MEDICINES MANAGEMENT CHECKLIST

Intravenous Cannulation Aseptic Technique Used

Intravenous Cannulation Aseptic Technique Used

INTRAVENOUS CANNULA 1 Indication

INTRAVENOUS CANNULA 2 Indication

INTRAVENOUS CANNULA 3 Indication

Intravenous Cannulation Aseptic Technique Used

Intravenous Cannulation Aseptic Technique Used

Intravenous Cannulation Aseptic Technique Used

INTRAVENOUS CANNULA 4 Indication

INTRAVENOUS CANNULA 5 Indication

INTRAVENOUS CANNULA 6 Indication

88 - 92% 94 - 98% Other

CIRCLE TARGET OXYGEN SATURATION

OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED

88 - 92% 94 - 98% Other

CIRCLE TARGET OXYGEN SATURATION

OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED

REGULAR ANTIMICROBIAL THERAPY

MEDICINE (approved name)

COURSE LENGTH VERIFICATION No.

MEDICINE (approved name)

COURSE LENGTH VERIFICATION No.

MEDICINE (approved name)

COURSE LENGTH VERIFICATION No.

MEDICINE (approved name)

COURSE LENGTH VERIFICATION No.

5 Drug not on ward

6 Omission - other treatment in progress

ENTER DOSE AGAINST TIME REQUIRED

using a cloth ONCE daily

Use to wash hair TWICE A WEEK

Nasal Antibiotic Cream

PRESCRIBERS SIGNATURE & NAME

If for treatment prescribe in Regular Medicine

21 MEDICINE (approved name)

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

ENTER DOSE AGAINST TIME REQUIRED

23 MEDICINE (approved name)

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

5 Drug not on ward

6 Omission - other treatment in progress

ENTER DOSE AGAINST TIME REQUIRED

27 MEDICINE (approved name)

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME

Bleep No. PHARMACIST

PRESCRIBERS SIGNATURE & NAME