Student Name: Room: Name: Age: Male/Female Day 1 Day 2 Nurse

:

MULTI-PATIENT MED PASS WORK SHEET Dx: Hx: Allergies: Activity (tests, procedures): Special orders: IV Therapy: T: P: T: P: T: P: T: P: MEDICATION SHEET
Category Action

VITAL SIGNS @ 0800 VITAL SIGNS @1200 VITAL SIGNS @ 0800 VITAL SIGNS @ 1200
Name (generic/TRADE) Dose Route Frequency

R: R: R: R:
Reason for administration

BP: BP: BP: BP:

CBG: CBG: CBG: CBG:
Side effects Nursing interventions

Pt. Initials Diagnosis

1

MEDICATION SHEET
Pt. Initials Diagnosis Name (generic/TRADE) Dose Route Frequency Category Action Reason for administration Side effects Nursing interventions

2

PRN MEDICATIONS
Pt. Initials Diagnosis Name (generic/TRADE) Dose Route Frequency Category Action Reason for administration Side effects Nursing interventions

3

4

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