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WWG512B
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FOR TEACHING USE ONLY - NOT TO BE USED FOR PATIENT CARE
DO NOT ADMINISTER ANY MEDICATION TO A PATIENT BASED ON THIS CHART KCL
DRUG PRESCRIPTION AND ADMINISTRATION CHART
WARD w,tJ{D -
CONSULTANT
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Std( p■llenfa prinled lab. he111 FOUNDATION DR / CANDIDATE

UNIT No.
STUDENT
Oil~€ NO

Chart Written
JtJ("1JtfrMI!. DATE OF ADMISSION
/I'll II to/ 1
SURNAME

FIRST NAME F,,

JT A1Jltff1 (:. PACT / SPECIALITY
CODE
I,

DATE OF BIRTH o I Jo I / t.OO ( TTO's prescribed I TTO's dispensed '

Drug Allergy/
Significant Adverse
Reaction
ves,4'oNE KNOWN°:)
Specify Drugs
Dr. Sign/ ture
Date ..
NL A
.!(J'J..! .7:. ......
l...f.f.!ll.f!.L.'J.......... I
I

'
ONCE ONLY & PREMEDICATION DRUGS '\ ·.
DOCTORS Time Given/> I'-,.. ~HARMACY
DATE DRUG DOSE TIME ROUTE
SIGNATURE Gillen
by' \

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Time
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REGULAR
PRESCRIPTIONS ADDITION~
TREAT~ENT
Route ~OE OOS£1ROute CH~Cl£OC,-
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ru 1 Initials lnrtiai. {; I V£ I )/ P,r,,,,_cy
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----
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' -- Date
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Valld Period
Date

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Initials

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- Date Pharmacy
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Date

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Date
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"' - Date Date Pharmacy
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d Period
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~
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14,/f l Initials Initials
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CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Addlt1onal Information

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t Ttc,/1 I •f/h ,''" I
DATE
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 AS REQUIRED PRESCRIPTIONS

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Data

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rture - ,~:;~J -..
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Time
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Dose
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Additional lntonnation Given by
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Valid Period
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Date
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0018
IRoute
Start Date Valid Period
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iven k ~
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Valid PJ!riod
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Valid Pcrioct.
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p~
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Addiuonal,lnformation
' ~- Given by -
DRUG (APPROVED NAME)
Date - 1...-
Doae
I
-
Route Start Date Valid Period

DOClot'a S1gn1ture
Time
- 1...-

--
Max. Freq. Pharmacy
Dose 1...-

--
AddiU<lnal lnformauon
Given by -