MEDICATION RECORD

Date/ Time:
Name of Date Date Dosage Special Purpose Size, Prescription Physician Side
Medication Started Stopped Instructions Shape, of Physician Phone effects
Color number
 MEDICATION RECORD

Name:

Date Medication Dose Given Frequency Time Am

Pm
 FLUID ORDERS
Name: Registration no.:
Method Method Site
and site
Fluid Type Amount Addition Duration From To Rate
(ml) (hrs/min) ml/hr
date time date time
1.
2.
3.
4.
5.
6.
7.
8.
TOTAL:
SAMPLE

FLUID ORDERS
Name: Razina S. Arasal Registration no.: 041900
Method and Method Site
site Intravenous Infusion Central Venous line, Left Jugular vein
Fluid Type Amount Addition Duration From To Rate
(ml) (hrs/min) date time date time ml/hr

1. Total 2000 ml 24 hrs 04/19/0 8:00 04/20/0 8:00 83

Parentera 0 A.M. 0 A.M.
l Nutrition
Solution
2.
3.
4.
5.
6.
7.
8.
TOTAL: 2000 ml 24 hrs

FLUID ORDERS
Name: Razina S. Arasal Registration no.: 041900
Method Method Site
and site Intravenous Infusion Peripheral vein left hand
Fluid Type Amount Addition Duration From To Rate
(ml) (hrs/min) date time date time ml/hr

1. Norma 500 ml 2 gm 12 hrs 04/19/0 8:00 04/19/0 8:00 42

l Saline KCL 0 A.M. 0 P.M.
2. Normal 500 ml 2 gm 12 HRS 04/19/00 8:01 04/20/00 8:00 42
Saline KCL P.M A.M
3.
4.
5.
6.
7.
8.
TOTAL: 2000 ml 24 hrs