Form Ph-0021 - 21 Day Medication Administration Record - Medication Pass Nutrition Supplement Program

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21 Day Medication Administration
Record – Medication Pass Nutrition
Supplement Program
Allergies: _________________________________________________________________________________
Contraindication for Use
When patient is assessed by Speech Language Pathologist (SLP) for viscosity tolerance and Med Pass is deemed to not be safe, SLP will:
- advise nurse that if patient is on Med Pass, it should be discontinued. Nurse will place any existing Med Pass orders on hold by writing “On hold due to
viscosity intolerance. Dietitian notified”. AND - contact Clinical Dietitian to write order to discontinue Med Pass and re-assess.
Date
Administration (Admin) Period
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Admin Time
Weigh patient weekly on ____________
Resource 2 (nutrition supplement)
[Nutrition Supplement Name]
_____ mL po _____ times daily
*Order revised on ________________
To _____ mL po _____ times daily
Date
Weigh patient weekly on ____________
Admin Time
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Resource 2 (nutrition supplement)
[Nutrition Supplement Name]
_____ mL po _____ times daily
*Order revised on ________________
To:
_____ mL po _____ times daily
weigh patient _______ on _______
Date
Weigh patient _________ on ___________
Admin Time
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Resource 2 (nutrition supplement)
[Nutrition Supplement Name]
_____ mL po _____ times daily
*Order revised on ________________
To:
_____ mL po _____ times daily
weigh patient _______ on _______
Codes: / = dose not due
MAR reconciled by:
Date & Time:
PH-0021
Chart Divider Section # 8 – Dark Blue
Forms Committee Approval February 2017
Created July 2016
Revised February 2017
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