DRUGS NOT ADMINISTERED

WWG512B

Use codes to indicate why a drug has not been administered

FOR TEACHING USE ONLY - NOT TO BE USED FOR PATIENT CARE
DO NOT ADMINISTER ANY MEDICATION TO A PATIENT BASED ON THIS CHART
KCL
• Write the code in the signature box where the drug should have been given
•
•
Write the code on the back of the drug chart in the drug administered section
Entries must be signed by the Registered Practitioner who did not administer the drug
DRUG PRESCRIPTION AND ADMINISTRATION CHART
WARD CONSULTANT
1 Prescription unclear 5 Patient could not receive 9 NBM/unable to swallow
2 Allergy 6 Patient refused drug 0 Other Stick patient’s printed label here FOUNDATION DR / CANDIDATE
STUDENT NO
3 Outside range 7 Drug not available UNIT No. Chart Written
4 Patient away from ward 8 On instruction from Dr DATE OF ADMISSION
SURNAME
PACT / SPECIALITY
DATE TIME DRUG NURSE’S SIGNATURE REASON FIRST NAME CODE

DATE OF BIRTH TTO’s prescribed TTO’s dispensed

Drug Allergy/ YES/NONE KNOWN Dr. Signature ....................

Significant Adverse Specify Drugs
Date ..................................
Reaction

ONCE ONLY & PREMEDICATION DRUGS

e y
DOCTORS Time Given
DATE DRUG DOSE TIME ROUTE PHARMACY

us nly
SIGNATURE Given by

us nl
al O

al O
e
ic se

ic e
in s
in U

cl U
cl g

r ng
r in
fo h

fo hi
c

ot ac
ot a
N Te

N e T
r

ORAL ANTICOAGULANT
r
Drug (Approved Name) Date
Fo

Time
INR
Fo

Doctor’s Signature
Dose
6 pm
Dr. Initials
Date Pharmacy
Given by
WEIGHT ................................. HEIGHT ......................................
REGULAR ADDITIONAL TREATMENTS e.g. CAPD DRUGS ON ADMISSION
BODY SURFACE AREA ..............................................................
PRESCRIPTIONS DRUG DOSE FREQUENCY DATE STARTED
DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

e y

e y
us nl
Date Valid Period Doctor’s Signature Date Date Pharmacy

us nl
Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

al O

al O
Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

ic se

ic se
DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

Date
in U Valid Period Doctor’s Signature Date Date Pharmacy

in U
Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information
cl g

cl g
Date Valid Period Doctor’s Signature Date Date Pharmacy
r in

r in
Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information
fo h

fo h
Date Valid Period Doctor’s Signature Date Date Pharmacy
c

c
Initials Initials
ot a

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

ot a
N Te

N Te
Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information
r

r
Fo

Date Valid Period Doctor’s Signature Date Date Pharmacy

DRUG (APPROVED NAME) Dose Route

Initials

CHANGE DOSE/ROUTE
Initials

CHANGE DOSE/ROUTE Additional Information

Fo
Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

DRUG (APPROVED NAME) Dose Route CHANGE DOSE/ROUTE CHANGE DOSE/ROUTE Additional Information

Date Valid Period Doctor’s Signature Date Date Pharmacy

Initials Initials

Pharmacist Check
 WARD

Stick patient’s printed label here

UNIT No.
INTRAVENOUS & SUBCUTANEOUS INFUSIONS
SURNAME
USE OF CHART
1. Prescribed only those drugs to be given by infusion on the IV chart. FIRST NAME
Fo
2. State clearly the line through which the infusion fluid is to be administered e.g. intravenous, central venous
pressure (CVP) line, subcutaneous. r DATE OF BIRTH

ADDITIONS TO INFUSION INFUSION FLUID IV TIME TO FLUID SIGNATURES

DATE STARTING RUN BATCH
or LINE OR
TIME PRESCRIBER GIVEN BY CHECKEDBY PHARMACY
DRUG DOSE TYPE/STRENGTH VOLUME SC ML / HOUR No.
N Te
ot a
c
fo h
r in
cl g
in U
ic se
al O
us nl
e y

22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
22-00
18-00
12-00
08-00
TIMES
ENTER
TICK OR

REQUIRED
DATE
ENTER

Fo
r
N Te
ot a
c
fo h
r in
cl g
in U
ADMINISTRATION RECORD

ic se
al O
us nl
e y
 AS REQUIRED PRESCRIPTIONS AS REQUIRED PRESCRIPTIONS

DRUG (APPROVED NAME) DRUG (APPROVED NAME)

Date Date

Dose Route Start Date Valid Period Dose Route Start Date Valid Period
Time Time

Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy
Dose Dose

Additional Information Additional Information

Given by Given by

DRUG (APPROVED NAME) DRUG (APPROVED NAME)

Date Date

Dose Route Start Date Valid Period Dose Route Start Date Valid Period

e y
Time Time

e y
Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy

us nl
Dose Dose

us nl
Additional Information Additional Information
Given by Given by

al O

al O
DRUG (APPROVED NAME) DRUG (APPROVED NAME)
Date Date

Dose Route Start Date Valid Period Dose Route Start Date Valid Period
Time Time

ic se

ic se
Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy
Dose Dose

Additional Information Additional Information

in U
Given by Given by

in U
DRUG (APPROVED NAME) DRUG (APPROVED NAME)
Date Date
cl g
Dose Route Start Date Valid Period Dose Route Start Date Valid Period

cl g
Time Time
r in

Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy

r in
Dose Dose

Additional Information Additional Information

Given by Given by
fo h

fo h
DRUG (APPROVED NAME) DRUG (APPROVED NAME)
Date Date
c

c
Dose Route Start Date Valid Period Dose Route Start Date Valid Period
Time Time
ot a

ot a
Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy
N Te

Dose Dose

N Te
Additional Information Additional Information
Given by Given by

DRUG (APPROVED NAME) DRUG (APPROVED NAME)

Date Date
r

Dose Route Start Date Valid Period Dose Route Start Date Valid Period

r
Time Time
Fo

Doctor’s Signature Max. Freq. Pharmacy

Dose
Fo
Doctor’s Signature Max. Freq. Pharmacy
Dose

Additional Information Additional Information

Given by Given by

DRUG (APPROVED NAME) DRUG (APPROVED NAME)

Date Date

Dose Route Start Date Valid Period Dose Route Start Date Valid Period
Time Time

Doctor’s Signature Max. Freq. Pharmacy Doctor’s Signature Max. Freq. Pharmacy
Dose Dose

Additional Information Additional Information

Given by Given by