Attach ADR StickerLLERGIES & DVERSE NII known DRUG REACTIONS (ADR) Unknown 1110 oppqmob bt.i. or 00.1.011tO 13 Otbili Reaction/Type/Date bd.. $ Initials ug (or other) Sign Print Date •FAMILY NAMEGIVEN NAMECA NNAk D.O.B. Vkilif M.O. f-(Likc,s 1=1 MALE FEMALEADDRESS LOCATION/V4A-I 0 afis COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE First Prescriber to Print Patient Name and Check Label Correct: Weight(kg): Height(cm): Holes Punched as per AS2828 1: 2012BINDING MARGIN – NO WRITINGstralia 2005 – As amended 20130a 0 O 0OU C 0CUco0REGULAR MEDICATIONSYEAR 20.1.0.,._.,DATE & MONTHVARIABLE DOSE MEDICATIONDrug levelDateMedication (Print Generic Name)Time level takenRouteIndicationFrequencyPrescriber to enter dose times and individual dose PharmacyPrescriber Signature Print Your NameContactDosePrescriberTime to be given:Time given & SignVTE risk assessed: Yes 111 Prophylaxis not requiredDateMedication (Print Generic Name)Route rose Frequency & NOW Enter TimesIndication VTE Prophylaxis Prescriber SignaturePharmacyContraindicated Print Your NameContactMechanical ProphylaxisPrescriber/NI SignatureAMPrint Your NameContactPMDateWARFARIN (Marevan/Coumadin) select brandINR ResultRoutePrescriber to enter individual dosesTarget INR RangeIndicationPharmacyPrescriber SignaturePrint Your NameContactDOCTORS MUST ENTER administration timesDa Medication (Print Generic Name) Tick it N V ek-ANY), io Slow Release Rou e Dose Freluency & NOW Enter TimesIndication Pharmacy 0 rt.& vo .1.4,-(…witN,e-N Prescriber signature Print Your Name 75–f–vAkA Date, Niedication (Print Generic Name) t40.1.9 1 Pkt-A UtirveAD LRoute Do.,se Frequency e NOW Enter Times k 4k/A k Indicatign Pharmacy resonber SignatureDate rPrint Your NameMedication (Print Generic Name) Frequency & NOW Enter Times tContact Dosemgr mg mg Prescriber 1600 (Nurse 1) Nurse 2Contacthck It IloieawRvu I 1MA Dose Indication t1/4111 RiAsk,PharmacyPrescriber SignaturePrint Your Name ‘ ‘V0‘ LCContact0 bon 101 •—••D.. Pharmaceutical Review:r0 0 >– cO ›-o RECOMMENDED ADMINISTRATION TIMES GUIDELINES ONLYMorning Mane 0800Night Nate1800 or 2000Twice BD a day Three times a day neguiar 6 hourly RegUtar 8 hrly 8 hourly Four times DID a day08002000TDS 08000600 0600 06001400200012001800240014002200120018002200WARFARIN EDUCATION RECORD Patient Educated by Sign-Date: Given Warfarin Book: Sign, DateSlowSR = Sustained, modified or controlled release formulation. If scored tablet, then half can be given. Dose must be swallowed without crushing.REASON FOR NURSE NOT ADMINISTERING Codes MUST be circledAbsentFastingRefused – notify DrVomitingOn leaveNot available – obtain supply or contact DrWithheld – enter reason in clinical recordSelf AdministeredCheck if patient has another Medication Chart 2YEAR 20 & MONTH DOCTORS MUST ENTER administration times -or-Date Medication (Print Generic Name) Tick if Slow Yes/No Yes/No Release Route Dose Frequency & NOW Enter Times Contact: Date: Pharmacist . Indication Pharmacy Prescriber Signature Print Your Name Contact Date Medication (Print Generic Name) Dose Frequency & NOW Enter limes Slow I. Tick if Release Route Indication Pharmacy disch Prescriber Signature Print Your Name Contact Date Medication (Print Generic Name) f Tick if Slow Release Route Dose Frequency & NOW Enter Times MMIIIIII. Indication 1 Print Your Pharmacy I disch Prescriber Signature Name Contact Date Medication (Print Generic Name) Tick if Slow Release Route J Dose Frequency & NOW Enter Times large? lays a Indication Pharmacy Prescriber Signature Print Your Name Contact Date Medication (Print Generic Name) Tick if Slow Release Route Dose Frequency & NOW Enter Times large? lays C Indication Pharmacy Prescriber Signature Print Your Name Contact Date Medication (Print Generic Name) Tick if Slow Release Route Dose Frequency & NOW Enter Times Indication Pharmacy arge? aysC Prescriber Signature Print Your Name Contact Pharmaceutical Review:Check if patient has another Medication Chart 3-IVA V _LON0 0 7:] C r—m CD r-m CO r-
