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MCN Form 013

Lyceum of the Philippines University


College of Nursing

Name: Mrs. C(Baby) Age 24 years old

Diagnosis Hospital RMC-21-


No. 0122
Ward/RM LR-DR

Medication Administration Record (MAR)

PRESCRIPTION DATE
Time
09/14/21

Change Dose/ Frequency Change Dose/ Frequency


DRUG !0:00pm
Vitamin K 1mg deep IM

Date/Time: 09/14/21@2200H
Date/Time: Date/Time_________________
Signature _________________
Signature_________________ Signature_________________
MCN Form 013

DRUG Change Dose/ Frequency Change Dose/ Frequency


!0:00pm

Erythromycin ointment on both


eyes

Date/Time: 09/14/21 @2200H


Date/Time_________________ Date/Time_________________
Signature _________________
Signature_________________ Signature_________________

DRUG Change Dose/ Frequency Change Dose/ Frequency


!0:00pm
BCG

Date/Time: 09/14/21 @ 2200H Date/Time_________________


Date/Time_________________
Signature _________________ Signature_________________
Signature_________________

DRUG Change Dose/ Frequency Change Dose/ Frequency


!0:00pm
Hepatitis B, 0.5ml
IM (Intramuscular)

Date/Time: 09/14/21@2200H Date/Time_________________ Date/Time_________________

Signature _________________ Signature_________________ Signature_________________


MCN Form 013

Change Dose/ Frequency Change Dose/ Frequency


DRUG

Date/Time_________________ Date/Time_________________
Date/Time_________________
Signature_________________ Signature_________________
Signature _________________

Change Dose/ Frequency DRUG


DRUG Change Dose/ Frequency

Date/Time_________________ Date/Time_________________ Date/Time_________________

Signature _________________ Signature_________________ Signature_________________

Change Dose/ Frequency Change Dose/ Frequency


DRUG

Date/Time_________________ Date/Time_________________ Date/Time_________________

Signature _________________ Signature_________________ Signature_________________


MCN Form 013

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