Just In Case Medication Chart - 2014 Page 4
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4PATIENT NAME:__________________________________ DOB:_______________________________________________
PRESCRIBERS SIGNATURE
DATE
TIME
MEDICINE ADDED TO SYRINGE PUMP
DILUENT
ROUTE
APPROVED NAME
DOSE
PRESCRIBER TO STATE AND INITIAL THE
S/C
REASON FOR THE SYRINGE PUMP
EOL Care
Initials
Symptom
Initials
Management
BATTERY
STOP
SITE
SITE
LEVEL
START
START
DATE
TIME
DOSE GIVEN
GIVEN/CHECKED BY
POSITION
CONDITION
(CHANGE IF
RATE
VOLUME
DATE
TIME
<40%)
PRESCRIBERS SIGNATURE
DATE
TIME
MEDICINE ADDED TO SYRINGE PUMP
DILUENT
ROUTE
APPROVED NAME
DOSE
PRESCRIBER TO STATE AND INITIAL THE
S/C
REASON FOR THE SYRINGE PUMP
EOL Care
Initials
Symptom
Initials
Management
BATTERY
STOP
SITE
SITE
LEVEL
START
START
DATE
TIME
DOSE GIVEN
GIVEN/CHECKED BY
POSITION
CONDITION
(CHANGE IF
RATE
VOLUME
DATE
TIME
<40%)
When a patient does not receive a prescribed dose, the nurse should enter one of the code numbers given below in the administration box to explain the reason for non-administration.
1. Doctor’s request
2. Patient not at home at time prescribed medication due
3. Patient unable to receive medicines/no access
4. Patient refused medicine
5. Medicines unavailable
6. See patient notes
Trial September – December 2014
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