Medway School of Pharmacy 2010/11

Adapted from various hospital prescription charts

Maritime Hospitals Trust

INPATIENT PRESCRIPTION CHART
DRUG SENSITIVITY
Hospital: Anson

Weight (kg)

Ward: Elderly
Consultant:

Diet:

Height (m)

60

care

Trust

Tick if
active
oncology chart

Patients own medicines

Qty

Suitable
for use?

Y/ N
Y/N
Y/N
Y/N
Y/N
Y/N

Were drugs not suitable for use sent to

Pharmacy?

Y/N
Y/N
Y/N

Patient consent to use medicines on ward or

10.10.1930

Address: 5
Gender:

railway street, Newtown

M

OR USE PATIENT LABEL

ENSURE THAT ALL PATIENTS DETAILS

ARE COMPLETED

To Doctors: 1. Write legibly and avoid abbreviations.

2. Use generic name and metric dose. Write
micrograms and units in full.
3. Order in appropriate section and sign to
legalise prescription.
4. For any changes in the order, new
prescription must be written.
5. Discontinue a drug by entering the stop
date, draw a line through administration
panel, then initial it.
6. Prescriptions for antibiotics must include a
stop date.
7. Always make a relevant entry in drug
sensitivity box e.g. NOT KNOWN, NONE

To Nurses: -

destroy medicines as appropriate

Patient signature:
Date:
By / at discharge were
unused medicines
returned to: (tick box)

D.O.B.:

INSTRUCTIONS

- Number of items brought in

Drug

12345
Surname: Senior
First Name: A
Hospital No:

NKDA

1. The nurse administering the drug should

initial the appropriate box in the
administration column.
2. In the event of non-administration of a drug,
enter appropriate code (see bottom of
prescription chart) in the appropriate box;
give reason to the doctor and document in
the nursing record.

Patient?
Pharmacy?

ONCE ONLY AND PRE-ANAESTHETIC MEDICATION

Date

Time
prescribed

DRUG
(approved name)

Route

Dose

Doctors
signature

Given
by

Time
given

Pharmacy

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission as
appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes

Medway School of Pharmacy 2010/11

Adapted from various hospital prescription charts

REGULAR PRESCRIPTIONS
Patient Name

A Senior

2010

Month

Year

Drug Name:
(Generic)

Hospital Number

October .

Date

Additional instructions:

(osteomyelitis) for 2 weeks

0600
0800
1200
1800
2400

Sign Doctor

Date

0000

Dose

2g

Flucloxacillin
Route

INF

Grant

Drug Name:
(Generic)
Dose

500mg

Freq.

6h

Fucidin
Route

Freq.

Start

inf

tds

13.10.10

Sign Doctor

28.10.10

Pharmacist

13.10.10

Drug Name:
(Generic)

Stop

one hour (osteomyelitis)

Date

Grant

500mg

Stop
28.10.10

Pharmacist

13.10.10

Additional instructions:Over

Dose

Start

13.10.10

oral

6h

Start

28.10.10

2200

Stop

0800
1200

Sign Doctor

Date

0000

Drug Name:
(Generic)

Fucidin

10mL

Route

oral

Pharmacist

Freq.

tds

Start

for two weeks

Sign Doctor

Date

Grant

13.10.10

Stop

28.10.10

Additional instructions:

Route

Freq.

Pharmacist

Additional instructions:
Sign Doctor

Date

Pharmacist

Hq

Bt

Hq

Hq

Hq

hq

lm

Bt

lm

Hq

Bt

Hq

hq

0600

0800
1300

it

2200

Start

lm

29

fc

fc

1800

fc

0000

Drug Name:
(Generic)
Dose

Bt

fc

2200

Dose

lm

1800

for four weeks

13.10.10

28

it
it

Additional instructions:

Grant

27

1800

0600

Freq.

26

0000

Flucloxacillin
Route

0600
0800
1400

12345

Stop

0600
0800
1300
1800
2200
0000

Drugs Omitted: Nurses, please enter these codes on the chart. The doctor should be informed of the omission as
appropriate
1 Patient vomiting
2 Not on ward
3 Not able to take by mouth 4 - Refused
5 Drug unavailable
6 Instructions
7 Omitted medical
8 Other reason, specify in
unclear or illegible
instruction
nursing notes