St.

Paul University Philippines Tuguegarao

City, Cagayan

Bachelor of Science in Nursing - 2

College of Nursing
DUMMY CHART

Name of Patient: Krisha Mae Aquino Case Number: 107

Age: 27 Physician: DR. Balganion

Birthdate: 12/26/1997 Diagnosis: G3P2 Delivery
Date Admitted: 4/27/2022 Room Number: RM 490

MEDICATION SHEET
Medication Shift Time and Signature Remarks
Generic Name: Meperidine
AM
Brand Name: Demerol
Dosage: 50mg 7:45 PM Suzete-Anne administered
PM Pagaduan
Route: IV injection

Frequency: PRN
Night
Skin Test
Generic Name: Promethazine
AM
Brand Name: Phenergan
Dosage: 25mg 7:45 PM Suzete-Anne administered
PM Pagaduan
Route: IV Injection

Frequency: PRN
Night
Skin Test
Single Dose/STAT
Medication Name/Dose/Route Date and Time Signature Remarks