Routine Drug Administration Record

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Med
Prescribing Physician: _________________________________________
Time
S
M
T
W
T
F
S
Medications: _______________ Rx:
Number(s): ______
No
Yes
Dosage: ___________________________ Date filled: _______________
Route:
P.O.
I.M.
S.C.
S.L.
Topical
Inhalation
Rectal
Times:
PRN
Daily
B.I.D.
T.I.D.
Q.I.D.
A.C.
P.C.
H.S.
Amount in bottle: _______________ Comments: ___________________
Med
Prescribing Physician: _________________________________________
Time
S
M
T
W
T
F
S
Medications: _______________ Rx:
Number(s): ______
No
Yes
Dosage: ___________________________ Date filled: _______________
Route:
P.O.
I.M.
S.C.
S.L.
Topical
Inhalation
Rectal
Times:
PRN
Daily
B.I.D.
T.I.D.
Q.I.D.
A.C.
P.C.
H.S.
Amount in bottle: _______________ Comments: ___________________
Prescribing Physician: _________________________________________
Med
Medications: _______________ Rx:
Number(s): ______
Time
S
M
T
W
T
F
S
No
Yes
Dosage: ___________________________ Date filled: _______________
Route:
P.O.
I.M.
S.C.
S.L.
Topical
Inhalation
Rectal
Times:
PRN
Daily
B.I.D.
T.I.D.
Q.I.D.
A.C.
P.C.
H.S.
Amount in bottle: _______________ Comments: ___________________
Prescribing Physician: _________________________________________
Med
Medications: _______________ Rx:
Number(s): ______
Time
S
M
T
W
T
F
S
No
Yes
Dosage: ___________________________ Date filled: _______________
Route:
P.O.
I.M.
S.C.
S.L.
Topical
Inhalation
Rectal
Times:
PRN
Daily
B.I.D.
T.I.D.
Q.I.D.
A.C.
P.C.
H.S.
Amount in bottle: _______________ Comments: ___________________
Prescribing Physician: _________________________________________
Med
Medications: _______________ Rx:
Number(s): ______
Time
S
M
T
W
T
F
S
No
Yes
Dosage: ___________________________ Date filled: _______________
Route:
P.O.
I.M.
S.C.
S.L.
Topical
Inhalation
Rectal
Times:
PRN
Daily
B.I.D.
T.I.D.
Q.I.D.
A.C.
P.C.
H.S.
Amount in bottle: _______________ Comments: ___________________
P.O. = by mouth
I.M. = intermuscular
S.C. = sub-cutaneous
S.L. = sub-lingual-under-tongue
PRN = as needed
B.I.D. = two times a day
T.I.D. = three times a day
Q.I.D. = four times a day
A.C. = before meals
P.C. = after meals
H.S. = hours of sleep (taken at bedtime)

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