PATIENT NAME:_______________________ DATE:______________________________

PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

NSD(REGULAR)

DRUGS & MEDICINE (OR/DR) QTY QTY RETURNED TOTAL QTY

IRRIGATION 1L 1
0.9 NORMAL SALINE 100CC BBM 1
0.9 NORMAL SALINE 50CC 1
ATROPINE SULFATE 1
BACTICIDE 10% SOLUTION 120ML 1
BACTICIDE 7.5% CLEANSER 120ML / POVIDONE IODINE 1
BUTORPHANOL 1
DIPHENHYDRAMINE / SONIPHEN 1
EPINEPHRINE 1
EUROCAINE 1
PLASIL 1
STERILE WATER FOR INJ. 5ML 2
ZEFXON 1
FLUIDS
D5 LR 1L 1
PLAIN LR 1L 1
PNSS 1L 1

ADD ONS:
COXIDIA 4
CEFUREX 4
REMOPAIN 1

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY (RPH): ___________________________
PATIENT NAME:_______________________ DATE:______________________________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

CS (REGULAR)
DRUGS & MEDICINE QTY QTY RETURNED TOTAL QTY

0.9 NORMAL SALINE 100CC BBM 1

0.9 NORMAL SALINE 50CC 1
ATROPINE SULFATE 1
BACTICIDE 10% SOLUTION 120ML 2
BACTICIDE 7.5% CLEANSER 120ML 1
BUTORPHANOL 1
DIPHENHYDRAMINE/ SONIPHEN 1
EPINEPHRINE 1
EUROCAINE POLYAMP 1
HEMOSTAN / NEXAVELL 2
IRRIGATION 1L 2
ONZET / ZOFRAN 1
PLASIL / METVEX 1
PYREX / INFULGAN 1GM/IV 3
REMOPAIN / XEVOLAC 5
STERILE WATER FOR INJ. 5ML 2
ZEFXON 1
FLUIDS
D5 LR 1L 1
D5 NM 1L 1
D5 NR 1L 1
PLAIN LR 1L 1
PNSS 1L 1
PROTEMIN 1
ORAL MEDS
CEFUREX/ EURIMAX / ZINNAT 6
COXIDIA 6
ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:_______________________ DATE:______________________________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

D & C(REGULAR)

DRUGS & MEDICINE QTY QTY RETURNED TOTAL QTY

IRRIGATION 1L 1
0.9 NORMAL SALINE 100CC BBM 1
0.9 NORMAL SALINE 50CC 1
ATROPINE SULFATE 1
BACTICIDE 10% SOLUTION 120ML 1
BACTICIDE 7.5% CLEANSER 120ML 1
BUTORPHANOL 1
DIPHENHYDRAMINE/ SONIPHEN 1
EPINEPHRINE 1
EUROCAINE 1
PLASIL / METVEX 1
STERILE WATER FOR INJ. 5ML 2
REMOPAIN / XEVOLAC 1
ZEFXON 1
FLUIDS
D5 LR 1L 1
PLAIN LR 1L 1

ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:_______________________ DATE:______________________________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

(MAJOR) ____________________
DRUGS & MEDICINE QTY QTY RETURNED TOTAL QTY

0.9 NORMAL SALINE 100CC BBM 1

0.9 NORMAL SALINE 50CC 1
ATROPINE SULFATE 1
BACTICIDE 10% SOLUTION 120ML 2
BACTICIDE 7.5% CLEANSER 120ML 1
BUTORPHANOL 1
DIPHENHYDRAMINE / SONIPHEN 1
EPINEPHRINE 1
EUROCAINE POLYAMP 2
HEMOSTAN / NEXAVELL 2
IRRIGATION 1L 2
ONZET / ZOFRAN 1
PLASIL / METVEX / VITAMEX 1
PYREX / INFULGAN 1GM/IV 3
REMOPAIN / XEVOLAC 5
STERILE WATER FOR INJ. 5ML 2
ZEFXON 1
FLUIDS
D5 LR 1L 1
D5 NM 1L 1
D5 NR 1L 1
PLAIN LR 1L 1
PNSS 1L 1
PROTEMIN 1
ORAL MEDS
COXIDIA 4
CEFUREX/ EURIMAX / ZINNAT 4
ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:__________________ DATE:______________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:_______________________

OR PROCEDURE:

(LOCAL) ___________________________
QTY

QTY
DRUGS & MEDICINE
RETURNED TOTAL QTY
IRRIGATION 1L 1
BACTICIDE CLEANSER 120ML 1
BACTICIDE SOLUTION 120ML 1
EPINEPHRINE AMP. 1
STERILE WATER INJ. 5ML 2
XYLOCAINE / EUROCAINE 5

ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:_______________________ DATE:______________________________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

HYSTEROSCOPY

DRUGS & MEDICINE QTY QTY RETURNED TOTAL QTY

EPINEPHRINE / ADRENALINE 1
BACTICIDE 10% SOLUTION 120ML 1
BACTICIDE 7.5% CLEANSER 120ML 1
D5 0.9 NSS 1L(P) 1
D5 LR 1L(P) 1
IRRIGATION 1L 1
PNSS 1L (P) 6
TRAMAL 1

ADD ONS:
ZEFXON 1
0.9 NORMAL SALINE 100CC BBM 1
REMOPAIN / XEVOLAC 1

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:_______________________ DATE:______________________________
PHYSICIAN:__________________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

PUI (MAJOR) ____________________

DRUGS & MEDICINE QTY QTY RETURNED TOTAL QTY

0.9 NORMAL SALINE 100CC BBM 1

0.9 NORMAL SALINE 50CC 1
ATROPINE SULFATE 1
BACTICIDE 10% SOLUTION 120ML 2
BACTICIDE 7.5% CLEANSER 120ML 1
BUTORPHANOL 1
DIPHENHYDRAMINE / SONIPHEN 1
EPINEPHRINE 1
EUROCAINE POLYAMP 2
HEMOSTAN / NEXAVELL 2
IRRIGATION 1L 2
ONZET / ZOFRAN 1
PLASIL / METVEX / VITAMEX 1
PYREX / INFULGAN 1GM/IV 3
REMOPAIN / XEVOLAC 5
STERILE WATER FOR INJ. 5ML 4
ZEFXON 1
FLUIDS
D5 LR 1L 1
D5 NM 1L 1
D5 NR 1L 1
PLAIN LR 1L 1
PNSS 1L 1
PROTEMIN 1
ORAL MEDS
COXIDIA 4
CEFUREX/ EURIMAX / ZINNAT 4
ANTIBIOTIC
MONOWEL VIAL 1G 2
PROFUREX VIAL 750MG 2
CEFAZOLIN 1 GM VIAL 2
EURIMAX VIAL 750MG 2
CETAJECT AMP 3
ADD ONS

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:__________________ DATE:______________
PHYSICIAN:______________________
ANESTHESIOLOGIST:_____________

LABOR ROOM ITEMS( FOR NON- MP PATIENTS ONLY)

QTY

QTY
DRUGS & MEDICINE
RETURNED TOTAL QTY
D5 LR 1L 1
BUSCOPAN AMP 3
STERILE WATER INJ. 5ML 2

ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________

________________________________________________________________________________

PATIENT NAME:__________________ DATE:______________

PHYSICIAN:______________________
ANESTHESIOLOGIST:_____________

LABOR ROOM ITEMS( FOR NON- MP PATIENTS ONLY)

QTY
QTY

DRUGS & MEDICINE

RETURNED TOTAL QTY
D5 LR 1L 1
BUSCOPAN AMP 3
STERILE WATER INJ. 5ML 2

ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________
PATIENT NAME:__________________ DATE:______________
PHYSICIAN:___________________
ANESTHESIOLOGIST:__________________

OR PROCEDURE:

CATARACT

QTY

QTY
DRUGS & MEDICINE
RETURNED TOTAL QTY
NORMAL SALINE 500M 1
XYLOCAINE 2% POLYAMP 2
BACTICIDE CLEANSER 120ML 1
BALANCED SALT SOLUTION 500ML 1
SENSOMED ERYTHROMYCIN OPTH 1

ADD ONS:

PREPARED BY (RPH): __________________________

ISSUED TO (RN): _____________________________
CHARGED BY(RPH): _____________________________