Standard Treatment Guidelines

Serial No Dosage Drugs Dose Duration Route

Form & Dose
Interval

Prescribed Medicines
Serial No Dosage Drugs Dose Duration Route
Form & Dose
Interval

Q1 Is the name of the drug written legibly?

1 2 3 4 5 6

Q2 Is the strength written or not?

1 2 3 4 5 6

Q3 Is the dose of prescribed medication written?

 1 2 3 4 5 6

Q4 Is the dosage form mentioned?

1 2 3 4 5 6

Q5 Is the frequency of drug mentioned?

1 2 3 4 5 6

Q6 Is the route of administration mentioned?

1 2 3 4 5 6

Q7 Are abbreviation used?

1 2 3 4 5 6

Q8 Are all the drugs administered on time?

1 2 3 4 5 6

Q9 Is antibiotic prescribed or not? If yes, then name them.

1 2 3 4 5 6

Q10 Is patient suffering from any adverse drug reaction?

1 2 3 4 5 6

Q11 Total number of drug prescribed?

1 2 3 4 5 6
Q12 Medicines used by generic and brand name:-

1 2 3 4 5 6

Q13 Any ayurvedic/homeopathic medicines used?

1 2 3 4 5 6

Conclusion
Pros:

Cons:

Drugs Combination if Used:

Rationality of Prescribed Medicines

Final Remarks About Rationality
1.

2.

 Drug Combination if used:

Cost Factor:
 No/Yes adverse effects
