OLD
ALLERGIES & ADVERSE REACTIONS (ADR)
( ) No Known . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ./. . . /. . . . Drug Alert Signature Date ( ) Drug Alert PERSONAL PARTICULARS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /. . . ./. . . . Signature Date
DR UG AL E R T L AB E L
Client’s Surname Given Name:
Client Preferred Name:
Date of Birth:
Client No.
ATTAC H AL E R T L AB E L HE R E AND WHE R E INDIC ATE D INS IDE C HAR T Enter Details:
7 RIGHTS’ OF MEDICATION ASSISTANCE
2. 3. 4. 5. 6.
Right Person Check Right Drug or medication Right Dose these Right Time / Date / Day 5 rights Right Route (which way is medication 3 times given, orally, topically etc) 7. Write it Down - Staff sign when medication has been administered. REFER TO CARE PLAN ROUTINE
DOSE OMITTED CODES
Medications not able to be given should be recorded in Client’s Notes
Crush
Observe Swallowing Encouragement Needed
Absent
A
Not Required
N/R
Whole
Adjusted Administration
A/T
Omitted
O
Thickened Fluids
Fasting
F
Refused - Notify Dr
R
Hospital
H
Self Administering
S
On Leave Withheld - Enter reason in Clinical Record No Stock
L
Vomitting Withheld - Pending Results Unusable (eg. dropped)
V
W
N
Peg Other
W/R
U
VACCINATIONS
S cheduled C hildhood Vaccine UTD
Yes
No
Influenza Vac c ine
- Date L as t G iven:
/
/
P neumococcal Vaccine
- Date L as t G iven:
/
/
Tetanus Vac c ine
- Date L as t G iven:
/
/
Hep A/ B Vac c ine
- Date L as t G iven:
/
/
- Date L as t G iven:
/
/
- Date L as t G iven:
/
/
- Date L as t G iven:
/
/
PRESCRIBER PARTICULARS
Phone No. ENTITLEMENT NUMBERS
PHARMACY PARTICULARS
Pharmaceutical Benefits Entitlement Number
/ / VALID TO
02/13 Phone No.
Medicare Number
/ / VALID TO
© COPYRIGHT COMPACT BUSINESS SYSTEMS PTY LTD 2010
Community Medication Record
1. Right Method - Obtain details from Care Plan eg. break in half, crush, put into yogurt etc.
D.O.B.
Client No.
ADR ALERT
Month: PACKED MEDICATIONS
REGULAR MEDICATION ORDERS
Times
SIGN IN THIS PANEL FOR ALL PACKED MEDICATION SIGN FOR INDIVIDUAL MEDICATION IN THE PANELS BELOW R egular Medic ation
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
INDIVIDUAL MEDICATION ORDERS 1-8
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
Frequency
Apply Medical Director Medication Adhesive Label
1
2
Yes
20 3
4
5
6
7
8
9
10
11
No 12
(Circle) 13
14
15
PACKED
Client’s Name
MEDICATION
16
17
18
19
20
21
22
23
24
Page 1
25
26
27
28
29
30
31
1
2
20 3
4
5
6
7
8
9
10
11
12
13
14
15
PACKED
Month:
Page 2
MEDICATION
16
17
18
19
20
21
22
23
24
Page 3
25
26
27
28
29
30
31
1
2
20 3
4
5
6
7
8
9
10
11
12
13
14
15
PACKED
Month:
Page 4
MEDICATION
16
17
18
19
20
21
22
23
24
Page 5
25
26
27
28
29
30
31
1
2
20 3
4
5
6
7
8
9
10
11
12
13
14
15
PACKED
Month:
Page 6
MEDICATION
16
17
18
19
20
21
22
23
24
Page 7
25
26
27
28
29
30
31
1
2
20 3
4
5
6
7
8
9
10
11
12
13
14
15
PACKED
Month:
Page 8
MEDICATION
16
17
18
19
20
21
22
23
24
Page 9
25
26
27
28
29
30
31
1
2
20 3
4
5
6
7
8
9
10
11
12
13
14
15
PACKED
Month:
Page 10
ADR ALERT 17
18
19
20
21
22
23
24
25
26
27
28
29
30
(Circle)
MEDICATION NOTES
31
REGULAR MEDICATIONS 1
16
No
FOLD ON THIS LINE TO USE AS A 12 MONTH CHART
MEDICATION
Yes
Page 11
R egular Medic ation Adminis tration
Client’s Name
D.O.B.
Client No.
ADR ALERT
Month: REGULAR MEDICATION ORDERS 9 TO 17 R egular Medic ation
Time
1
2
Yes
20 3
4
5
6
7
8
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
R egular Medic ation
Frequency
Dose
Route Prescriber Signature
Date
Prescriber Signature
Stop Date
Frequency
Apply Medical Director Medication Adhesive Label
Page 12
9
10
11
No 12
(Circle) 13
14
15
16
17
18
19
20
21
22
23
24
Page 13
25
26
27
28
29
30
31
Month: 1
2
20 3
4
5
6
7
8
Page 14
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Page 15
25
26
27
28
29
30
31
Month: 1
2
20 3
4
5
6
7
8
Page 16
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Page 17
25
26
27
28
29
30
31
Month: 1
2
20 3
4
5
6
7
8
Page 18
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Page 19
25
26
27
28
29
30
31
Month: 1
2
20 3
4
5
6
7
8
Page 20
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Page 21
25
26
27
28
29
30
31
Month: 1
2
20 3
4
5
6
7
8
Page 22
9
10
11
12
13
14
15
ADR ALERT Yes 17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
(Circle)
MEDICATION NOTES
REGULAR MEDICATIONS 2 - (SHORT TERM & VERBAL ORDERS BACK PAGE)
16
No
Page 23
R egular Medic ation Adminis tration
Client’s Name
D.O.B.
SHORT TERM MEDICATION ORDERS Short Term Medication
Dose
Client No. Month:
ADR ALERT Yes
20
No
(Circle)
Dates Times
Route Dr Signature
Start Date
Dr Signature
Stop Date
Short Term Medication
Frequency Dose
Dates Times
Route Dr Signature
Start Date
Dr Signature
Stop Date
Short Term Medication
Frequency Dose
Dates Times
Route Dr Signature
Start Date
Dr Signature
Stop Date
Short Term Medication
Frequency Dose
Dates Times
Route Dr Signature
Start Date
Dr Signature
Stop Date
Short Term Medication
Frequency Dose
Dates Times
Route Dr Signature
Start Date
Dr Signature
Stop Date
Frequency
PRN (When Required) Medication Orders Dose
PRN Medication
Doctors Signature
Date
Doctors Signature
Stop Date
/
/
/
Route Frequency Dose
Doctors Signature
Date
Doctors Signature
Stop Date /
/
Route Frequency Dose
Doctors Signature
Date
Doctors Signature
Stop Date /
/
Route Frequency Dose
Doctors Signature
Date
Doctors Signature
Stop Date /
Max Dose / 24 Hours
/
PRN Medication
/
Max Dose / 24 Hours
/
PRN Medication
/
Max Dose / 24 Hours
/
PRN Medication
/
R eas on / Ins truc tions
/
/
Route Frequency
Max Dose / 24 Hours
Date Time Qty.
S ig. Date Time Qty.
S ig.
VERBAL / TELEPHONE ORDERS - VALID FOR 24 HOURS ONLY NOTE: To Cancel - Draw diagonal line through entry after 24 hours. If Doctor is using Compact confirmation labels, insert label number in column provided Date
Medication
Time
Dose
Date
Medication
Time
Dose
Date
Medication
Time
Dose
Route
Route
Route
Frequency
Frequency
Frequency
Doctor Name
RN Signature
Doctor Signature
2nd Signatory
Doctor Name
RN Signature
Doctor Signature
2nd Signatory
Doctor Name
RN Signature
Doctor Signature
2nd Signatory
CTO No.
ADMINISTRATION Time
Time
Time
Time
Time
Time
Given By Given By Given By Given By Given By Given By
CTO No.
Time
Time
Time
Time
Time
Time
Given By Given By Given By Given By Given By Given By
CTO No.
Time
Time
Time
Time
Time
Time
Given By Given By Given By Given By Given By Given By
NURSE INITIATED MEDICATION ORDERS Reason Nurse Initiated Medication
R.N. Signature
Start Date
Doctors Signature
Stop Date
Start Date
Doctors Signature
Stop Date
Sign.
Date
Time
Qty.
Sign.
Frequency
Route Frequency
Nurse Initiated Medication
Dose
R.N. Signature
Start Date
Doctors Signature
Stop Date
S ig.
Qty.
Dose
R.N. Signature
Qty .
Time
Route
Nurse Initiated Medication
Date Time
Date
Dose
Date Time
Route Frequency
Qty .
S ig.
Date Time
Qty .
S ig.
Date Time
Qty .
S ig.
Date Time
Qty .
S ig.
Date Time
Qty .
S ig.
Recommendations for Terminology, Abbreviations and Symbols used in the Prescribing and Administration of Medicines Supplied by: Australian Commission on Safety and Quality in Health Care www.safetyandquality.gov.au
DOSE FREQUENCY OR TIMING (in the) morning
morning, mane
(at) midday
midday
(at) night
night, nocte
twice a day
bd
three times a day
tds
four times a day
qid
every 4 hours
every 4 hrs, 4 hourly, 4 hrly
every 6 hours
every 6 hrs, 6 hourly, 6 hrly
every 8 hours once a week
when required
every 8 hrs, 8 hourly, 8 hrly once a week and specify the day in full, eg. once a week on Tuesdays three times a week and specify the exact days in full, eg. three times a week on Mondays, Wednesdays and Saturdays prn
immediately
stat
before food
before food
after food
after food
with food
with food
three times a week
ROUTE OF ADMINISTRATION epidural inhale, inhalation intraarticular intramuscular intrathecal intranasal intravenous irrigation left nebulised naso-gastric oral percutaneous enteral gastrostomy per vagina per rectum peripherally inserted central catheter right subcutaneous sublingual topical
DOSE FORMS capsule cream ear drops ear ointment eye drops eye ointment injection metered dose inhaler mixture ointment pessary powder suppository tablet patient controlled analgesia
DOSE OMITTED CODES cap cream ear drops ear ointment eye drops eye ointment inj metered dose inhaler, inhaler, MDI mixture ointment, oint pess powder supp tablet, tab PCA
24 HOUR CLOCK 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 11.00 12.00
AM - Morning .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... .................... ...................
0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 . 1200
PM - Afternoon 1.00 . . . . . . . . . . . . . . . . . . . . 1300 2.00 . . . . . . . . . . . . . . . . . . . . 1400 3.00 . . . . . . . . . . . . . . . . . . . . 1500 4.00 . . . . . . . . . . . . . . . . . . . . 1600 5.00 . . . . . . . . . . . . . . . . . . . . 1700 6.00 . . . . . . . . . . . . . . . . . . . . 1800 7.00 . . . . . . . . . . . . . . . . . . . . 1900 8.00 . . . . . . . . . . . . . . . . . . . . 2000 9.00 . . . . . . . . . . . . . . . . . . . . 2100 10.00 . . . . . . . . . . . . . . . . . . . . 2200 11.00 . . . . . . . . . . . . . . . . . . . . 2300 12.00 . . . . . . . . . . . . . . . . . . . . 2400
Long Term Community Medication Chart
Re-Order Ref. LTCC-01
170365
epidural inhale, inhalation intraarticular IM intrathecal intranasal IV irrigation left NEB NG PO PEG PV PR PICC right subcut subling topical
Medications not able to be given should be recorded in Client’s Notes Absent
A
Not Required
N/R
Adjusted Administration
A/T
Omitted
O
Fasting
F
Refused - Notify Dr
R
Hospital
H
Self Administering
S
On Leave Withheld - Enter reason in Clinical Record No Stock
L
Vomitting Withheld - Pending Results Unusable (eg. dropped)
V
W
N
W/R
U
UNITS OF MEASURE AND CONCENTRATION gram(s) International unit(s) unit(s) litre(s) milligram(s) millilitre(s) microgram(s) percentage millimole
g international unit(s) unit(s) L mg mL microgram, microg % mmol
ALL STATES Phone: 1800 777 508 Fax: (07) 3376 2001 Email: sales@compact.com.au Website: www.compact.com.au
NEW ZEALAND
International Freecall 0800 445 447 Fax: 61 7 3376 2001 Š Compact Business Systems Pty Ltd 2010 C opyright Notic e: This medic ation c hart and all forms in it are protected by Australian and International Copyright Laws. No part of them may be reproduced, transmitted or manipulated in any form or by any means electronic, digital or otherwise without obtaining prior written permission from Compact Business Systems Pty Ltd. This includes photocopying, scanning and posting the medication chart or any part of it online.