Prescriber Details
| Name | Prescriber No | Date | |
|---|---|---|---|
Allergies and Adverse Drug Reactions (ADR)
You can paste multiple allergies into the table below with the format:
medicine 1, reaction 1
medicine 2, reaction 2
| Medicine | Reaction | |
|---|---|---|
Regular Medications
| Medicine | Route | Dose | Frequency | Administration Times | Start Date | ||||
|---|---|---|---|---|---|---|---|---|---|
Variable Dose
| Medicine/Form | Route | Frequency | Date | Start Date | Drug Level | Time Taken | Dose | Prescriber Initials | |
|---|---|---|---|---|---|---|---|---|---|
VTE Prophylaxis
| Medicine | Route | Dose | Frequency | Prescriber | Mechanical Prophylaxis | Print Name | Start Date | |
|---|---|---|---|---|---|---|---|---|
Warfarin
| Route | Target INR Range | Indication | INR Result | Dose | Prescriber Initials | Start Date | |
|---|---|---|---|---|---|---|---|
PRN Medications
| Medicine | Route | Dose | Hourly Interval | Max PRN dose/24hr | Indication | Start Date | |
|---|---|---|---|---|---|---|---|
Intravenous Therapy Chart
| Infusion Fluid | Rate | Additives | Date | |
|---|---|---|---|---|