Just In Case Medication Chart - 2014
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4JUST IN CASE
MEDICATION CHART
DRUG ALLERGIES AND SENSITIVITIES
NAME:____________________________________
PLEASE TICK AS APPROPRIATE
ADDRESS:__________________________________
NONE KNOWN
YES
DRUG/ALLERGEN
DESCRIPTION OF REACTION
__________________________________________
INSERT PATIENT LABEL
THIS SECTION SHOULD BE COMPLETED PRIOR TO
URN:________________ JHC REF:________________
ADMINISTRATION OF ANY MEDICINE. REFER TO LOCAL POLICIES
DOB:________________ TEL:_____________________
FOR FURTHER GUIDANCE.
GP NAME-PLEASE PRINT
TELEPHONE OF GP
DATE
eGFR
RESULT
SIGNATURE
PRESCRIPTIONS FOR ONCE ONLY DRUGS
Date
Drug
Dose
Route
Time to
Special
Prescriber’s
Time
Given /
be given
instructions
signature
given
Checked
DATE
WATER FOR INJECTIONS
TIME
SIGNATURE
DATE
DOSE
CLINICAL INDICATION
GIVEN
BY
DRUG
DATE
DOSE
ROUTE
FREQUENCY
TIME
SIGNATURE
DATE
DOSE
CLINICAL INDICATION
GIVEN
BY
DRUG
DATE
DOSE
ROUTE
FREQUENCY
TIME
SIGNATURE
DATE
DOSE
CLINICAL INDICATION
GIVEN
BY
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Parent category: Medical