Blood/intravenous Infusion Fluid And Additive Chart
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1Blood/Intravenous Infusion
Fluid and Additive Chart
Unit No:
Instructions: Prescriber to sign even if no ‘ADDITIVE’ is ordered
Additives should not be added to blood products
SURNAME (block letters)
Consultant:
Ward:
Weight:
First Names:
Time to
Additive
Batch/
Signature
Date and Time
Type of Stock
Time
Time
Volume
Date
Volume
be
Bottle
IV Fluid
Prescriber’s
Pharmacist’s
started
Stopped
Infused
Dripset
IV Set
infused
Name and dose
Number
Witness
Signature
Signature
Changed
Changed
Electrolyte
Drug
Electrolyte
Drug
Electrolyte
Drug
Electrolyte
Drug
Electrolyte
Drug
Electrolyte
Drug
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