Name of client: __________________ Age: _____ Sex: _____ Date: _________

Room No. _____ Diagnosis:______________________________________________

Prescribing doctor: _______________________________________________________
Prepared by: ____________________________________________________________

Drug Indication Contraindication Mechanism of Action Side Effect/ Nursing Responsibilities

Adverse effect

Generic Name:

Brand Name:

Therapeutic

Pharmacologic
classification:

Dosage:

Route:

NAME OF STUDENT: SECTION: