Patient'S Vancomycin Monitoring Form

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Vancomycin Monitoring Form
Patient’s Name: _____________________________________ SSN/ MRN: ______________ Loc: __________
Age: ______ Gender: ______ Ht (in): ________ Actual BW (kg): ________ IBW (kg): _________
Allergies: _____________________________________________ Physician/Pager #: _________________________________
Site of Infection: ______________________________ GOAL TR _____________________ Date initiated: ________________
Day #
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
DATE
DOSE/
FREQ
TIME
TIME
TIME
Lab Data:
BUN/SCr
CrCl
WBC
Temp
Drug Levels:
Peak/
Time
Trough/
Time
Random/
Time
Analysis:
Microbiology:
Date
Date
Source
Findings
V (L)
K
t1/2
Initial dose
Exp P/T
Notes:

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