university hospitals of leicester nhs trust chart
TRANSCRIPT
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PATIENT DETAILS BSA(m2) Wt (kg) Ht
Anticoagulant Chemotherapy
Diabetes Syringe driver
Supplementary infusion chart Gentamicin/TobramycinOther (please specify) Haemodialysis
MEDICINE PRIOR TO ADMISSION NOT PRESCRIBED
D I S C H A R G E I N F O R M A T I O N
Medicine Dosage Freq. Reason
M E D I C I N E S M A N A G E M E N T C H E C K L I S T
DETAILS OF SUPPLEMENTARY CHARTS IN USE
Date Time to Medicine Dose Route Prescriber’s signature Bleep Date Time Givenbe given (approved name) and name No. given given by
PRESCRIPTION FOR ONCE-ONLY MEDICATION / PRE-ANAESTHETIC / ANTIMICROBIAL PROPHYLAXIS
Check Initial Date
Pre-admission
Drug history check
Source:
Rewritten drug chart checked
Allergy check
Patient’s own medicines
Self-administration
Compliance aidPatient discharge Initial Date
TTO written Signed
TTO supplied
Counselling
University Hospitals of LeicesterNHS Trust
ADULT INPAT IENT MEDICAT ION
A D M IN IS T R A T IO N R E C O R D
1
2
3
4
5
6
7
8
9
10
11
12
( C a u s o n 7 / 0 9 ) 6 0 9 0 6 2 3 K R
Chart of Consultant Ward Site
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8/18/2019 University Hospitals of Leicester NHS Trust Chart
2/12C O D E F O R D R U G O M I S S I O N S When drug is notadministered, record theappropriate number in thebox,circle and sign.Doctorsto be informed at discretion of nurse.
I V C A N N U L AT I O N
O X Y G E N T H E R A P Y
DRUG OXYGEN
DATE ADMINISTERED
OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED
DAT E
09
14
18
22
3
CIRCLE TARGET OXYGEN SATURATION
88 - 92% 94 - 98% Other
PRN / Continuous(refer to O2 guideline)
Tick here if saturationnot indicated
Signature:
Date:
Print name:
DRUG OXYGEN
DATE ADMINISTERED
OXYGEN SHOULD NOT BE WITHHELD WHILST AWAITING A PRESCRIPTION, IF IT IS REQUIRED
DAT E
09
14
18
22
4
CIRCLE TARGET OXYGEN SATURATION
88 - 92% 94 - 98% Other
PRN / Continuous(refer to O2 guideline)
Tick here if saturationnot indicated
Signature:
Date:
Print name:
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 1
PhlebitisScore
0-5
Removal Date
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 2
PhlebitisScore
0-5
Removal Date
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 3
PhlebitisScore
0-5
Removal Date
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 4
PhlebitisScore
0-5
Removal Date
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 5
PhlebitisScore
0-5
Removal Date
Intravenous Cannulation Aseptic Technique Used
Date Inserted
Inserter’s Name/Signature/Bleep
Insertion Site
Date
Score
Signature
IndicationINTRAVENOUS CANNULA 6
PhlebitisScore
0-5
Removal Date
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Sign
Date
Dose change
INDICATION
STOP
after
5 days
(unless
otherwise
stated)
COURSE LENGTH VERIFICATION No. PHARMACIST
SUPPLY
MEDICINE (approved name)
SPECIAL INSTRUCTIONS
Bleep no.
PRESCRIBER’SSIGNATURE & NAME
DATE
Morning
Midday
Teatime
Bedtime
Specify timerequired
Dose
15
ENTER DOSE AGAINST TIME REQUIRED YEAR
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
SWITCH FROM IV ROUTE TO ORAL AS SOON AS POSSIBLE - MAX 48HRS
Date
Route
Sign
Date
Dose change
INDICATION
STOP
after
5 days
(unless
otherwise
stated)
COURSE LENGTH VERIFICATION No. PHARMACIST
SUPPLY
MEDICINE (approved name)
SPECIAL INSTRUCTIONS
Bleep no.
PRESCRIBER’SSIGNATURE & NAME
DATE
Morning
Midday
Teatime
Bedtime
Specify timerequired
Dose
16 Date
Route
Sign
Date
Dose change
INDICATION
STOP
after
5 days
(unless
otherwise
stated)
COURSE LENGTH VERIFICATION No. PHARMACIST
SUPPLY
MEDICINE (approved name)
SPECIAL INSTRUCTIONS
Bleep no.
PRESCRIBER’SSIGNATURE & NAME
DATE
Morning
Midday
Teatime
Bedtime
Specify timerequired
Dose
17 Date
Route
Sign
Date
Dose change
INDICATION
STOPafter
5 days
(unless
otherwise
stated)
COURSE LENGTH VERIFICATION No. PHARMACIST
SUPPLY
MEDICINE (approved name)
SPECIAL INSTRUCTIONS
Bleep no.
PRESCRIBER’SSIGNATURE & NAME
DATE
Morning
Midday
Teatime
Bedtime
Specify timerequired
Dose
18 Date
Route
1 Declined 2 Vomiting/Nausea 3 Nil by mouth 4 Not required 5 Drug not on ward 6 Omission - other treatment in progress7 Noaccess(NG PEG/IV) 8 Unableto take 9 Patient not onward 10Inappropriate /unc lear prescript ion 11Await ingmedica ladvice 12Self-administration
I V
C A
NN UL AT I ON
/ OX Y GE N
T HE R AP Y
/ R E G UL AR
ANT I M
I C R OB I AL T HE R AP Y
R E G U L A R A N T I M I C R O B I A L T H E R A P Y
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ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
MRSA DECOLONISATIONPROPHYLAXIS REGIMEN
Antibacterial Wash
Use to wash hair TWICE A WEEK
For highrisk patients only
Nasal Antibiotic Cream
Brand:
Prescriber’s signature: Dr D Jenkins
Apply directly onto skinusing a cloth ONCE daily
instead of soap
Apply to bothnostrils
THREE/ ………..times a day
SPECIAL INSTRUCTIONS
If for treatment prescribe in Regular Medicine
PHARMACIST
SUPPLY
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME Bleep NoDate
Route
Teatime
DALTEPARIN
Dose
Sign
Date
Dose change
0
9
Brand:
INDICATIONFOR THROMBOPROPHYLAXISONLY
SC
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
2
C O D E F O R D R U G O M I S S I O N S When drug is not administered, record the appropriate number in the box, circle and sign. Doctors to be informed at discretion of nurse.
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INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
DateMorning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
23
1 Declined 2 Vomiting/Nausea 3 Nil by mouth 4 Not required 5 Drug not on ward 6 Omission - other treatment in progress7 No access (NG PEG/IV) 8 Unable to take 9 Patient not on ward 10 Inappropriate/unclear prescription 11 Awaiting medical advice 12 Self-administration
ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
24
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
25
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
26
R E G UL AR
M
E DI C I NE S
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8/18/2019 University Hospitals of Leicester NHS Trust Chart
6/12C O D E F O R D R U G O M I S S I O N S When drug is not administered, record the appropriate number in the box, circle and sign. Doctors to be informed at discretion of nurse.
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
DateMorning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
7
ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
8
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
9
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
0
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INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
DateMorning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
31
1 Declined 2 Vomiting/Nausea 3 Nil by mouth 4 Not required 5 Drug not on ward 6 Omission - other treatment in progress7 No access (NG PEG/IV) 8 Unable to take 9 Patient not on ward 10 Inappropriate/unclear prescription 11 Awaiting medical advice 12 Self-administration
ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
32
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
33
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
34
R E G UL AR
M
E DI C I NE S
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8/18/2019 University Hospitals of Leicester NHS Trust Chart
8/12C O D E F O R D R U G O M I S S I O N S When drug is not administered, record the appropriate number in the box, circle and sign. Doctors to be informed at discretion of nurse.
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
DateMorning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
5
ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
6
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
7
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
8
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INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
DateMorning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
39
1 Declined 2 Vomiting/Nausea 3 Nil by mouth 4 Not required 5 Drug not on ward 6 Omission - other treatment in progress7 No access (NG PEG/IV) 8 Unable to take 9 Patient not on ward 10 Inappropriate/unclear prescription 11 Awaiting medical advice 12 Self-administration
ENTER DOSE AGAINST TIME REQUIRED YEAR
DATE
MORNING (AROUND 0800); MIDDAY (BETWEEN 1200 & 1400); TEATIME (AROUND 1800); BEDTIME (AROUND 2200)
R E G U L A R M E D I C I N E S
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Dose
against Time Dose
40
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
41
INDICATION SPECIAL INSTRUCTIONS PHARMACISTBleep No.
SUPPLY POD
MEDICINE (approved name)
PRESCRIBER’S SIGNATURE & NAME
Date Dose change
Route Sign
Date
Morning
Midday
Teatime
Bedtime
Enter Doseagainst Time Dose
42
R E G UL AR
M
E DI C I NE S
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MEDICINE3
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
A S R E Q U I R E D M E D I C I N E S
MEDICINE4
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE5
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE6
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE7
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE9
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE8
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
C O D E F O R D R U G O M I S S I O N S When drug is not administered, record the appropriate number in the box, circle and sign. Doctors to be informed at discretion of nurse.
-
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MEDICINE50
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
DRUG ALLERGIES (MUST BE COMPLETED)
Medicine Reaction
No known allergies
Signature Designation Date
S No.
Patient’s name
Date of birth
A S R E Q U I R E D M E D I C I N E S
MEDICINE51
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE52
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE53
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE54
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE56
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
MEDICINE55
PHARM. SUPPLYSIGN BLEEP No.GIVEN
DATE
INDICATION MAX FREQUENCY
DOSE ROUTE
DATE
TIME
DOSE
ROUTE
A S
R E Q UI R E D ME DI C I NE S
1 Declined 2 Vomiting/Nausea 3 Nil by mouth 4 Not required 5 Drug not on ward 6 Omission - other treatment in progress7 No access (NG PEG/IV) 8 Unable to take 9 Patient not on ward 10 Inappropriate/unclear prescription 11 Awaiting medical advice 12 Self-administration
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D a t e
T y p e / S t r e n g t h
V o l u m
e
M e d i c i n e
D o s e
R o u t e
T i m e t o
P r e s c r i b e r
F l u i d
S t
a r t
G i v e n
C h e c k e d
r u
n o r
B a t c h
T i m e
b y
b y
m
l / h r
N o .
I n f u s i o n F l u i d
A d d i t i o n s t o I n f
u s i o n
S i g n a t u r e s
P A R E N T E
R A L I N F U S I O N S