3. Internal hospital doctor and patient medical forms
DRUGS NOT ADMINISTERED
DATE TIME DRUG REASON ACTION TAKEN NURSES SIGNATURE
SEE CODE BELOW
When dose varies with route of AS REQUIRED PRESCRIPTIONS OTHER PRESCRIPTIONS IN USE (Tick Box) IV INFUSION CHART IV FLUID CHART DIABETIC CHART SALBUTAMOL CHART PCA/NCA TPN OF
administration prescribe separately DATE TIME DOSE ROUTE GIVEN BY CHECKED BY DATE TIME DOSE ROUTE GIVEN BY CHECKED BY DATE TIME DOSE ROUTE GIVEN BY CHECKED BY
DRUG ALLERGIES DOSE
CHECKED
PRESCRIBER
INITIALS
MAX DOSE/24 ROUTE
___________ mcg/mg/g/units per kg/___________ Hrs
INDICATION
WARD CONSULTANT DATE OF ADMISSION
SIGNATURE IN FULL PHARMACY START
PRINT NAME + BLEEP
DRUG ALLERGIES DOSE
CHECKED
PRESCRIBER
___________ mcg/mg/g/units per kg/___________
INITIALS
MAX DOSE/24
Hrs
ROUTE BARTS AND THE LONDON CHILDREN’S HOSPITAL
TWO WEEK IN-PATIENT MEDICATION PRESCRIPTION
INDICATION
SIGNATURE IN FULL PHARMACY START
PRINT NAME + BLEEP
DRUG ALLERGIES DOSE
AND ADMINISTRATION RECORD
CHECKED
PRESCRIBER
INITIALS MEDICINES ON ADMISSION (Reconciliation to be completed by pharmacy)
MAX DOSE/24 ROUTE
___________ mcg/mg/g/units per kg/___________
Hrs Medications on Admissions: number items Liquid or Tablet PEG / PEJ / NG / NJ Please circle if appropriate
INDICATION WHEN DRUG IS NOT ADMINISTERED RECORD THE APPROPRIATE NUMBER IN THE BOX AND DETAIL ACTION TAKEN (OPPOSITE): Œ PATIENT AWAY FROM WARD PATIENT COULD NOT RECEIVE – CHECK POLICY
SIGNATURE IN FULL PHARMACY START Ž PATIENT REFUSED DRUG DRUG NOT AVAILABLE – OBTAIN A SUPPLY ON INSTRUCTION OF DOCTOR ‘ OTHER ’ PATIENT SELF ADMINISTERED
PRINT NAME + BLEEP
DRUG ALLERGIES DOSE
CHECKED
PRESCRIBER INTRAVENOUS FLUSHES
INITIALS
MAX DOSE/24 ROUTE
___________ mcg/mg/g/units per kg/___________
Hrs DATE TIME GIVEN BY CHECK BY DATE TIME GIVEN BY CHECK BY DATE TIME GIVEN BY CHECK BY DATE TIME GIVEN BY CHECK BY DATE TIME GIVEN BY CHECK BY
INDICATION
DRUG (APPROVED NAME)
SIGNATURE IN FULL PHARMACY START
DOSE STRENGTH START DATE FREQUENCY
PRINT NAME + BLEEP TYPE OF ACCESS PHARM
DRUG ALLERGIES DOSE SIGNATURE PRINT NAME AND BLEEP ALL CHECK
CHECKED
PRESCRIBER ADDITIONAL INSTRUCTIONS
INITIALS
MAX DOSE/24 ROUTE DRUG (APPROVED NAME)
___________ mcg/mg/g/units per kg/___________
INDICATION
Hrs DOSE STRENGTH START DATE FREQUENCY Source: GP (ph) / (written) Pt Parents PODs Notes ............. eTTA ............. Other Recorded by: Initials Contact No. Date
TYPE OF ACCESS PHARM
SIGNATURE IN FULL PHARMACY START
SIGNATURE PRINT NAME AND BLEEP ALL CHECK
PRINT NAME + BLEEP ADDITIONAL INSTRUCTIONS
TAKE HOME MEDICINES (TTAs)
DRUG ALLERGIES
CHECKED
DOSE DRUG (APPROVED NAME) PHARMACY CHECK DATE COMMENTS
PRESCRIBER DOSE STRENGTH START DATE FREQUENCY
INITIALS
MAX DOSE/24 ROUTE TYPE OF ACCESS PHARM
___________ mcg/mg/g/units per kg/___________
Hrs SIGNATURE PRINT NAME AND BLEEP ALL CHECK DISPOSAL OF PATIENTS OWN MEDICINES
INDICATION
ADDITIONAL INSTRUCTIONS
SIGNATURE IN FULL PHARMACY START
DRUG (APPROVED NAME) (See the Trust Policy for the Use of Patients Own Medicines for guidance on when disposal is appropriate).
PRINT NAME + BLEEP DOSE STRENGTH START DATE FREQUENCY This section should be completed by the nurse/pharmacist/doctor and signed by the patient or their carer. The medicine
DRUG ALLERGIES DOSE TYPE OF ACCESS PHARM
must then be sent to the pharmacy for disposal.
CHECKED
PRESCRIBER SIGNATURE PRINT NAME AND BLEEP ALL CHECK I consent to the disposal of the following medicines:
INITIALS
Ametop/Emla (circle as appropriate) MAX DOSE/24 ROUTE ADDITIONAL INSTRUCTIONS 1
Hrs 2 Signed
INDICATION
Patient/Carer
SIGNATURE IN FULL PHARMACY START Dated
PRINT NAME + BLEEP
BLT0110
CUT OUT CUT OUT
HOSPITAL NO.
ALLERGIES & ADVERSE DRUG REACTIONS (ADR)
SURNAME
DRUG / OTHER ALLERGENS REACTION SOURCE INITIAL & DATE
GIVEN NAME
ALLERGY
Nil Known Drug (or other) Not Possible to Ascertain
Sticker
Attach
(Confirm ASAP)
DATE OF BIRTH SEX M F
Weight (kg) Height (cm) BSA(m2)
DATE INITIAL DATE INITIAL DATE INITIAL
Weight Weight Weight
Condition(s) where medications are contraindicated?
PRESCRIPTIONS MUST BE REVIEWED AND REWRITTEN EVERY TWO WEEKS OR SOONER REBOARDING CHECKED BY PHARMACIST PRESCRIPTIONS MUST BE REVIEWED AND REWRITTEN EVERY TWO WEEKS OR SOONER REBOARDING CHECKED BY PHARMACIST
ENTER DOSE AGAINST REQUIRED USE ONE ROUTE ONLY FOR EACH ENTRY REGULAR PRESCRIPTION MONTH YEAR ENTER DOSE AGAINST REQUIRED USE ONE ROUTE ONLY FOR EACH ENTRY REGULAR PRESCRIPTION MONTH YEAR
ALLERGIES STATE INITIAL DATE STATE INITIAL DATE
CHECKED
DATE TIME ONCE ONLY AND PRE-MEDICATION DRUGS DOSE ROUTE SIGNATURE, PRINT NAME + BLEEP GIVEN BY CHECKED
START DATE START DATE
PRESCRIBER
INITIALS
TIME
BY
PHARM SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
ADMISSION ADMISSION
DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY
CHECKED CHECKED
ROUTE PRINT NAME ROUTE PRINT NAME
PRESCRIBER PRESCRIBER
INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP
TIME DOSE DOSE DOSE TIME DOSE DOSE DOSE
STATE INITIAL DATE STATE INITIAL DATE
START DATE START DATE
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
ADMISSION ADMISSION
DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY
CHECKED CHECKED
ROUTE PRINT NAME ROUTE PRINT NAME
PRESCRIBER PRESCRIBER
INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP
TIME DOSE DOSE DOSE TIME DOSE DOSE DOSE
STATE INITIAL DATE STATE INITIAL DATE
START DATE
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
START DATE
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
ADMISSION ADMISSION
DRUG BLOOD LEVELS DATE DRUG OTHER INSTRUCTIONS ALLERGIES
CHECKED
SIGNATURE IN FULL PHARMACY DATE DRUG OTHER INSTRUCTIONS ALLERGIES
CHECKED
SIGNATURE IN FULL PHARMACY
ROUTE PRINT NAME ROUTE PRINT NAME
PRESCRIBER PRESCRIBER
INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP
DRUG DATE/TIME LEVEL COMMENTS / ACTION TAKEN DRUG DATE/TIME LEVEL COMMENTS / ACTION TAKEN TIME DOSE DOSE DOSE TIME DOSE DOSE DOSE
STATE INITIAL DATE STATE INITIAL DATE
START DATE
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
START DATE
SINCE START CHANGE CHANGE GIVEN CHECKED
BY BY
ADMISSION ADMISSION
DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY DATE DRUG OTHER INSTRUCTIONS ALLERGIES SIGNATURE IN FULL PHARMACY
CHECKED CHECKED
ROUTE PRINT NAME ROUTE PRINT NAME
PRESCRIBER PRESCRIBER
INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP INITIALS mcg/mg/g/units per kg/ INITIALS
BLEEP
TIME DOSE DOSE DOSE TIME DOSE DOSE DOSE