Ut In Omnibus Glorificetur Deus

SAN BEDA UNIVERSITY

COLLEGE OF NURSING

PATIENT-CENTERED DRUG STUDY/ ANALYSIS

STUDENT’S INFORMATION
Name: ______________________________________________________________ Year and Section: _____________
Group: ______ Agency/ Area: __________________________________________________________ Shift: ________
Inclusive Dates of Rotation: ___________________________ Clinical Instructor: ______________________________

PATIENT’S INFORMATION
Name of Patient: __________________________________________________________ Age: __________ Sex: _____
Chief Complaint: __________________________________________________________________________________
Diagnosis: _______________________________________________________________________________________

DRUG INFORMATION
Drug Classification: _______________________________ Generic Name: _________________________________
Dosage: ________________________________________ Brand Name: ___________________________________
Route of Administration: ____________________________

MODE/ MECHANISM OF ACTION

INDICATION CONTRAINDICATION

SIDE EFFECT AND ADVERSE REACTION

SBU.CON.RLE.2017.11.1 Page 1 of 2
 DRUG INTERACTIONS (Drug-Drug, Drug-Food, Drug-Laboratories)

NURSING CONSIDERATIONS/ HEALTH TEACHINGS

Prepared by: Evaluated by:

Student Nurse’s Signature over Printed Name Clinical Instructor’s Signature over Printed Name

DATE: _______________ DATE: _______________

SBU.CON.RLE.2017.11.1 Page 2 of 2