Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND

Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Student’s Name: Date:

SAMPLE MEDICATION RECORD FORM
Name : ______ Hospital Record No.
_
Allergies: Ward & Bed No. : _

Initial Ord. Disc. Med. Dose. Freq. Rt. Hour Date

Name Jan-June Descriptive Rating July-December Descrptive Rat

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Initials Printed Name Title Initials Printed Name Title

Initial Ord. Disc. Med. Dose. Freq. Rt. Hour Date

STAT/ONE TIME MEDS/PRE-OPS.

Date
Date Date Tim Date
Medication Time Give Init. Medication Init.
Ord. Ord. e Given
n

Name Jan-June Descriptive Rating July-December Descrptive Rat

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

OMISSION RECORD
Omission Reason Omission Site of Injection
Date Time Date Time
1. Right Arm
2. Left Arm
3. Right Gluteal
4. Left Gluteal
5. Right Thigh
6. Left Thigh
7. Right Abdomen
8. Left Abdomen

Route of
Administration
By mouth
PO
Intramuscular
IM
Intravenous IV
Subcutaneous
SC
Sublingual SL
Intradermal ID
Topical
TOP
Right Eye
OD
Left Eye
OS
Both Eyes
OU

SAMPLE INTRAVENOUS FLUID FORM

Medicine Nurse’s Initials

IV Fluid Duration of Flow Date Time
Added over Printed Name
Infusion Rate
S C DC S C DC

Name Jan-June Descriptive Rating July-December Descrptive Rat

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Name: Ward: Hosp. Record No. _

Legend: S - Started C- Consumed DC- Discontinued

SAMPLE INTAKE AND OUTPUT RECORD

Patient : Ward: Hospital Record No: Time:
TIME Nurse’s Initials
INTAKE OUTPUT
over Printed Name
6-2 I.V. Others
Oral O.F. Others Urine Stool Gastric
Shift Mainline Side drip
6-7
7-8
8-9
9-10
10-11
11-12
12-1
1-2
8 Hrs.
TOTAL
2-10 Oral O.F. I.V. Others Urine Stool Gastric Others Nurse’s Initials
Name Jan-June Descriptive Rating July-December Descrptive Rat
Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

over Printed Name

Shift
Mainline Side drip
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
8 Hrs.
TOTAL
Nurse’s Initials
10-6 I.V. Others
Oral O.F Others Urine Stool Gastric over Printed Name
Shift
Mainline Side drip
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
8Hrs.
TOTAL
24 Hrs.
TOTAL TOTAL INTAKE TOTAL OUTPUT:

Nurse’s Initials over Printed Name: ___________________________ Date: ___________________

Name Jan-June Descriptive Rating July-December Descrptive Rat

Transforming Communities through Science and Technology