POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Brgy. Kiagot, Digos City, Davao del Sur, Philippines 8002

DRUG STUDY
Name of Patient: Attending
Physician:__________________________________
Age: Sex: Civil Status:
Diagnosis:__________________________________________
Occupation: Religion: Chief
Complaint:_____________________________________
Address: Date of Admission: _________________
Ward: Room No: Bed No: ________

DATE/ BRAND ROUTE/ DRUG ADVERSE EFFECT NURSING

TIME NAME ACTION INDICATION DOSAGE/ INTERACTION PRECAUTION/ RESPONSIBILITIES
CONTRAINDICATIONS
ORDERE TIME
D INTERVAL
Precautionary Use:

GENERIC HALF-LIFE
NAME
Contraindicated:

CLASSIFI- ABSORPTION EXCRETION

CATION
Student Name: Year & Sec.: Group No.: Rating:__________________
References_______________________________________________________________________ Criteria: Promptness (15%), Format/Neatness (15%), Assessment (15%),
Nursing Diagnosis (15%), Objectives (15%), Objectives of Care (10%), Nursing Action (30%), Evaluation (10%)
Clinical Instructor:____________________________________