Private Hospital NIMC 11 DAY VERSION

AFFIX PATIENT IDENTIFICATION LABEL
Family Name:
Given Names:
DOB:
Sex
M
Private Hospital NIMC
11 DAY VERSION
AS REQUIRED
“PRN”
MEDICATIONS
NOT A VALID
PRESCRIPTION UNLESS
IDENTIFIERS PRESENT
UR No.
Attach ADR Sticker
F
See front page for details
1st Prescriber to Print Patient
Name and Check Label Correct:
Route
Prescriber Name (Print)
Prescriber Signature
Date
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Contact
Date
Max dose/24 hours
Indication
Pharmacy
Sign
Time
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Date
Max dose/24 hours
Indication
Pharmacy
Sign
Time
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Date
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Pharmacy
Contact
Sign
Date
Max dose/24 hours
Time
Indication
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Date
Max dose/24 hours
Indication
Pharmacy
Sign
Time
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Date
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Contact
Date
Max dose/24 hours
Indication
Pharmacy
Sign
Time
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Medication (use Generic Name) Print
Route
Dose
Hourly frequency
PRN
Date
Max dose/24 hours
Indication
Pharmacy
Sign
Time
Dose
Route
Prescriber Name (Print)
Prescriber Signature
Contact
Sign
cm
Ward/Unit:
ADDITIONAL CHARTS
IV Fluid
BGL/Insulin
PCA
Other
Palliative Care
Chemotherapy
IV Heparin
ONCE ONLY, PRE-MEDICATION & NURSE INITIATED MEDICINES
Date
Prescribed
Medication
(use Generic Name) Print
Route
Dose
Date/Time Prescriber/Nurse Initiator (NI)
of Dose Signature
Print Name
Given
by
Time
Given
Pharmacy
TELEPHONE ORDERS (To be signed within 24 hrs of order)
Date
Time
Medication
(use Generic Name) Print Route Dose
Frequency
Medicines taken Prior to Presentation to Hospital
(Prescribed, over the counter, complementary)
Medication
Nurse Initials
Nr 1 / Nr 2
Own medications brought in?
Dose & Frequency
Duration
Dr.
Sign
Dr Name
Y
Medication
Date
RECORD OF ADMINISTRATION
Time/
Given By
Time/
Given By
Time/
Given By
Time/
Given By
N Administration Aid (specify)
Dose & Frequency
Duration
N
O
I
T
A
R
T
S
I
N
I
M
D
A
R
NOT FO
GP:
Documented by:
© Commonwealth of Australia 2005 - As amended 2009.
Community Pharmacy:
(Sign:)
(Date)
Medicines usually administered by:
MR 21
Date
Contact
HEIGHT
OF
MEDICATION CHART
Date
Contact
kg
MEDICATION CHART
BINDING MARGIN - DO NOT WRITE
Date
Contact
PATIENT WEIGHT
BINDING MARGIN - DO NOT WRITE
Dose
Prescriber’s Signature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name (Print). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . . Pharmacist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . .
Indication
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Time
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
PRN
Pharmacy
Max dose/24 hours
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Hourly frequency
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Dose
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Route
Date
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Medication (use Generic Name) Print
Continue on discharge ? Yes / No
Dispense?
Yes / No
Duration?
days Qty?
Date
Year 20
AFFIX PATIENT IDENTIFICATION LABEL HERE & OVER LEAF
Attach ADR Sticker
ALLERGIES & ADVERSE REACTIONS (ADR)
Nil known
Drug (or other)
NOT A VALID
PRESCRIPTION UNLESS
IDENTIFIERS PRESENT
UR No.
Unknown (tick appropriate box or complete details below)
Reaction/Type/Date
Initials
Family Name:
Given Names:
DOB:
Sex
M
F
To reduce the risk of wrong identification label being placed on the chart
1st Prescriber to Print Patient
Name and Check Label Correct:
Sign . . . . . . . . . . . . . . . . . . . . . . . . . Print . . . . . . . . . . . . . . . . . . . . . Date. . . . . . . . . . . . . . . .
MEDICATION CHART INSTRUCTIONS
MEDICATION CHART INSTRUCTIONS
WARFARIN ORDERING SECTION
Patient Name
1st
PBS
RPBS
LE
P
M
A
EX NLY
O
2nd
( ) Appropriate box
Date
WARFARIN
Brand of Warfarin (Circle)
VARIABLE DOSE MEDICINES
DOSE
INR
Result
TIME
DOSE
Marevan / Coumadin
Route
1800
Target INR
Prescriber Name
Prescriber No.
Prescriber Signature
Pharmacy Quantity
Indication
6pm
Doctor
Contact
Nurse 1
Repeats
Patient Name
1st
( ) Appropriate box
mg
mg
mg
mg
mg
mg
mg
mg
mg
mg
Nurse 2
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
It is recommended that a laminated copy of the Guidelines for Anticoagulation using Warfarin is available to assist the
doctor/pharmacist/nurse when a patient is commenced on warfarin. The Guidelines offer information about target INR,
duration of therapy, dosing, management of excessive bleeding and drug interactions.
A standard dose time of 1600 hours (4 pm) or 1800 (6pm) is recommended as this allows the medical team caring for
the patient to order the next dose based on INR results.
The indication and target INR (based on Guidelines for Anticoagulation using Warfarin) should be included when warfarin
is initially ordered.
For each day of therapy, the following information should be documented:
- INR result.
- warfarin dose
- doctor’s initials
- initials of nurse that administers the dose and the checking nurse.
AS REQUIRED (“PRN” MEDICATIONS)
Frequency
OSE
D
E
EXAMPLE
L
B
VARIA ATION
EDIC
MONLY
.......................
PLE
M
EXA NLY
O
Indication
Repeats
Pharmacy
Date:. . . . . . . . . . . . . . . . . . .
.......................
Absent
A
Fasting
F
On Leave
L
Twice
A Day
BD
Not available - obtain
supply or contact Dr
N
Refused - Notify Dr
R
Self Administering
S
Three
Times
A Day
Four
Times
A Day
Six
Times
A Day
Withheld - enter reason
In Clinical Record
Indication
Pharmacy
Repeats
Quantity
0800 2000
TDS 0800 1400 2000
QID 0600 1200 1800 2200
4
Hourly 0200 0600 1000 1400 1800 2200
Antibiotic 8
8 Hourly Hourly 0600 1400 2200
W
05
Discharge
Required
Yes / No
Duration/
Qty
DR
Initials
Date
Patient Name
1st
PBS
RPBS
2nd
( ) Appropriate box
.
Duration/
Quantity
Dr.
Signature
COMMONLY USED AND UNDERSTOOD
ABBREVIATIONS
Abbreviation
Meaning
PO
per oral / by mouth
NG
nasogastric
sublingual
sublingual
IV
intravenous injection
IM
intramuscular injection
subcutaneous
subcutaneous
IT
intrathecal
PR
per rectum
PV
per vagina
Gutt
eye drop
Occ
eye ointment
Top
topical
MA
metered aerosol
Neb
nebulised / nebuliser
PCA
patient controlled analgesic
Tick if
Slow
release
SR = Sustained, modified or contolled release
formulation.
If scored tablet, then half can be given.
Dose must be swallowed without crushing.
RECOMMENDED WAY OF CHARTING MEDICATIONS TO BE GIVEN
LESS FREQUENTLY THAN DAILY
PRN
Contact
1800
or 2000
Antibiotic 6
6 Hourly Hourly 0600 1200 1800 2400
V
Hourly
Frequency
Prescriber Signature
Yes / No
Morning Mane 0800
Nocte
PBS
RPBS
Brand substitution not permitted
Prescriber Name
Prescriber No.
Discharge
Required
(GUIDELINES ONLY)
Night
( ) Appropriate box
Dose
Nurse
RECOMMENDED ADMINISTRATION TIMES
Date:. . . . . . . . . . . . . . . . . . .
The actual dose given must be recorded.
The person administering each dose is responsible for checking that the maximum daily dosage will not be
exceeded.
LE
P
M
A
X
E NLY
O
Time
Given
This section has been formatted to facilitate ordering of medicines that require variable dosing based on laboratory test
results or as a reducing protocol eg gentamicin and steroids. If these agents are ordered in the regular order section,
then there is no designated area to record drug levels and if they are ordered in the “once-only” ordering section, the
risk of errors of omission is increased.
For each day of therapy, the following information should be documented:
- Drug level results.
- Time drug level taken.
For each dose, the following information should be documented:
- Dose.
- Doctor’s initials
- Actual time of administration (this may be different from the dose time)
- Initials of nurse that administers the dose.
If a patient requires a second variable dose medication or twice daily dosing prescribe in the regular section using the
above format.
Vomiting
Route
Quantity
DOSE
Doctor
Contact
Given Warfarin Book/Information:
Administration:
Tick if
Slow
release
TIME
Dr to enter Dose Time & Individual Dose
Prescriber Name
Prescriber No.
Prescriber Signature
Sign: . . . . . . . . . . . . . . . . . . .
The medical officer must write:
- Dose and hourly frequency. “PRN” (pre-printed) alone is not sufficient.
- Indication and maximum daily dose (ie maximum dose in 24 hours) eg Paracetamol 4g/24 hrs
2nd
DOSE
Drug
Level
Time
Level
Taken
Patient Educated by:
Sign: . . . . . . . . . . . . . . . . . . .
Prescribing:
Drug (Generic Name)
Route
REASON FOR NURSE NOT
ADMINISTERING
WARFARIN EDUCATION RECORD
Because of the well documented risks associated with use of warfarin,
all patients should receive counselling about the use of warfarin and
given a warfarin book (available from Sigma pharmaceuticals). This
section is included as a record that these risk mitigation activities have
been completed.
1st
Medication (Use Generic Name) Print
CODES MUST BE CIRCLED
WARFARIN EDUCATION RECORD
Patient Name
Date
mg
The warfarin ordering section is printed in red as an extra alert to indicate that it is an anticoagulant (and a high-risk
medicine).
Date
PBS
RPBS
2nd
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Frequency
0600
RECOMMENDED
ADMINISTRATION TIMES
GUIDELINES ONLY
Clinical
Pharmacist
Review
Patient Name:
Clinical
Pharmacist
Review
Patient Name:
Morning Mane 0800
REGULAR MEDICATIONS
Patient Name
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Date
Medication (Use Generic Name) Print
OSE
D
E
L
B
VARIA ATION
MEDIC
Route
Frequency
Contact
Indication
Repeats
Patient Name
1st
Quantity
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Date
WARFARIN
Brand of Warfarin (Circle)
Marevan / Coumadin
Route
Prescriber No.
Indication
Prescriber Signature
Pharmacy Quantity
Patient Name
1st
Discharge
Required
DOSE
INR
Result
TIME
DOSE
6pm
Doctor
Contact
Nurse 1
Repeats
Yes / No
Duration/
Quantity
Dr.
Signature
Tick if
Slow
release
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Route
Dose
Prescriber Signature
Year 20
Date
0800 1400 2000
6
hrly
0600 1200 1800 2400
8
hrly
0600 1400 2200
QID
0600 1200 1800 2200
Date & Month
Administration times
Patient Name
1st
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
WARFARIN
EDUCATION RECORD
Date
Patient Educated by:
mg
mg
mg
mg
mg
mg
mg
mg
mg
mg
Drug (Generic Name)
Sign: . . . . . . . . . . . . . . . . . . .
Date:. . . . . . . . . . . . . . . . . . .
Given Warfarin Book/Information:
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
❑ PBS
❑ RPBS
2nd
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
.......................
Sign: . . . . . . . . . . . . . . . . . . .
Nurse 2
Discharge
Required
mg
Patient Name
1st
Quantity
(✓) Appropriate box
.......................
Yes / No
Duration/
Quantity
Dr.
Signature
Frequency
Quantity
Date:. . . . . . . . . . . . . . . . . . .
Tick if
Slow
release
(✓) Appropriate box
Drug (Generic Name)
2000
Nurse
❑ PBS
❑ RPBS
2nd
TDS
0800
REGULAR MEDICATIONS
Time
Given
1800
Target INR
Print Prescriber Name
DOSE
BD
Doctor
Dr to enter Dose Time & Individual Dose
Print Prescriber Name
Prescriber No.
Prescriber Signature
Pharmacy
Drug
Level
Time
Level
Taken
DOSE
TIME
Twice
a day
3 times a
day
Regular
6 Hourly
Regular
8 Hourly
4 times a
day
1800 or
2000
Nocte
SR=Sustained, modified
or controlled release
formulation.
If scored tablet, then half
can be given.
Dose must be swallowed
without crushing.
Contact
Date
Patient Name
1st
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
REASON FOR NURSE
NOT ADMINISTERING
Indication
Pharmacy
Quantity
Codes MUST be circled
Repeats
Discharge
Required
Date
Patient Name
1st
Yes / No
Duration/
Quantity
Dr.
Signature
❑ PBS
❑ RPBS
2nd
Absent
Fasting
Date
Refused - notify Dr
Patient Name
1st
Quantity
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
(✓) Appropriate box
Vomiting
Frequency
On leave
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Indication
Prescriber Signature
Contact
Pharmacy
Repeats
Quantity
Discharge
Required
Date
Patient Name
1st
Drug (Generic Name)
Yes / No
Duration/
Quantity
Dr.
Signature
Not available - obtain
supply or
contact Dr
Withheld - Enter
reason in Clinical
Record
Route
Dose
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Quantity
Patient Name
1st
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
(✓) Appropriate box
Frequency
Drug (Generic Name)
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Quantity
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber No.
Date
❑ PBS
❑ RPBS
2nd
Tick if
Slow
release
Self Administering
Discharge
Required
Yes / No
Duration/
Quantity
Dr.
Signature
157431
DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath
Administration times
1st
Date
Night
Tick if
Slow
release
Route
Dose
Quantity
Frequency
DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath
DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath
Year 20
Date & Month
TIME
Route
Frequency
Dr to enter Dose Time & Individual Dose
Print Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Medicare Australia/DVA copy - Valid for use as PBS at:
Repeats
Patient Name
Quantity
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Date
WARFARIN
Route
Target INR
Marevan / Coumadin
Print Prescriber Name
1800
6pm
Prescriber No.
Prescriber Signature
Medicare Australia/DVA copy - Valid for use as PBS at: Quantity
Date
Patient Name
1st
Contact
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber Signature
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Indication
Date
Prescriber No.
Patient Name
1st
2nd
Contact
Tick if
Slow
release
Route
Dose
Prescriber Signature
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Indication
Patient Name
1st
2nd
Tick if
Slow
release
Route
Dose
Print Prescriber Name
Indication
Prescriber No.
Prescriber Signature
Date
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Repeats
Tick if
Slow
release
PHARMACY
PRESCRIPTION
Prescriber No.
Patient Name
1st
Route
Dose
Prescriber Signature
Repeats
Frequency
Contact
Repeats
(✓) Appropriate box
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
PHARMACY
PRESCRIPTION
Prescriber No.
Prescriber Signature
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Patient Name
1st
Contact
Repeats
(✓) Appropriate box
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
PHARMACY
PRESCRIPTION
Prescriber No.
Prescriber Signature
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Patient Name
1st
Contact
Repeats
(✓) Appropriate box
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Indication
Prescriber No.
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
Date
Contact
Contact
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Indication
❑ PBS
❑ RPBS
❑ Brand substitution not permitted
Patient Name
1st
Print Prescriber Name
Indication
Frequency
Prescriber Signature
❑ Brand substitution not permitted
Repeats
(✓) Appropriate box
Drug (Generic Name)
Frequency
(✓) Appropriate box
Date
Contact
Dose
Prescriber Signature
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Contact
Repeats
PHARMACY
PRESCRIPTION
PHARMACY PRESCRIPTION
Date
Prescriber No.
PHARMACY
PRESCRIPTION
Prescriber No.
Drug (Generic Name)
❑ PBS
❑ RPBS
❑ Brand substitution not permitted
Print Prescriber Name
Date
Indication
Frequency
Route
Medicare Australia/DVA copy - Valid for Quantity
use as PBS at:
Indication
Repeats
(✓) Appropriate box
Drug (Generic Name)
Print Prescriber Name
Repeats
(✓) Appropriate box
Tick if
Slow
release
Tick if
Slow
release
❑ Brand substitution not permitted
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
(✓) Appropriate box
DOSE
TIME
Brand of Warfarin (Circle)
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
157431
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
DOSE
Patient Name
1st
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
Medication (Use Generic Name) Print
Date
Date
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
(✓) Appropriate box
PHARMACY PRESCRIPTION
1st
❑ PBS
❑ RPBS
2nd
PHARMACY PRESCRIPTION
Patient Name
1st
TIME
Route
Frequency
Dr to enter Dose Time & Individual Dose
Print Prescriber Name
Prescriber No.
Prescriber Signature
Pharmacist/Patient copy - Valid for use with PBS
Repeat Authorisation
Patient Name
Quantity
❑ PBS
❑ RPBS
2nd
(✓) Appropriate box
Date
WARFARIN
Route
Target INR
Prescriber Signature
Pharmacist/Patient copy - Valid for use with PBS
Repeat Authorisation
Date
Patient Name
1st
1800
Quantity
Contact
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Indication
Date
Prescriber No.
Patient Name
1st
Quantity
2nd
Contact
Tick if
Slow
release
Route
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Indication
Patient Name
1st
Quantity
2nd
Tick if
Slow
release
Route
Dose
Print Prescriber Name
Indication
Prescriber No.
Date
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Quantity
Repeats
Contact
PHARMACY
PRESCRIPTION
Prescriber No.
Patient Name
1st
❑ PBS
❑ RPBS
Route
Dose
Prescriber Signature
Quantity
Frequency
Contact
Repeats
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
PHARMACY
PRESCRIPTION
Prescriber No.
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Patient Name
1st
Quantity
Contact
Repeats
(✓) Appropriate box
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
PHARMACY
PRESCRIPTION
Prescriber No.
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Patient Name
1st
Quantity
Contact
Repeats
(✓) Appropriate box
Tick if
Slow
release
Route
Dose
Frequency
❑ Brand substitution not permitted
Print Prescriber Name
Indication
Prescriber No.
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Tick if
Slow
release
PHARMACY
PRESCRIPTION
Repeats
(✓) Appropriate box
Date
Contact
Tick if
Slow
release
Drug (Generic Name)
❑ PBS
❑ RPBS
❑ Brand substitution not permitted
Quantity
2nd
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Indication
Indication
Frequency
Patient Name
1st
Print Prescriber Name
Repeats
(✓) Appropriate box
Drug (Generic Name)
Prescriber Signature
❑ Brand substitution not permitted
Date
Contact
Frequency
(✓) Appropriate box
❑ PBS
❑ RPBS
Frequency
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Quantity
Contact
Repeats
PHARMACY
PRESCRIPTION
PHARMACY PRESCRIPTION
Date
Prescriber No.
PHARMACY
PRESCRIPTION
Prescriber No.
Drug (Generic Name)
Indication
❑ Brand substitution not permitted
Print Prescriber Name
Date
Repeats
(✓) Appropriate box
Drug (Generic Name)
Route
Pharmacist/Patient copy - Valid for
use with PBS Repeat Authorisation
Indication
Repeats
(✓) Appropriate box
Drug (Generic Name)
Print Prescriber Name
❑ PBS
❑ RPBS
2nd
Tick if
Slow
release
❑ Brand substitution not permitted
DOSE
6pm
Prescriber No.
(✓) Appropriate box
Repeats
TIME
Brand of Warfarin (Circle)
Marevan / Coumadin
Print Prescriber Name
Contact
PHARMACY
PRESCRIPTION
❑ PBS
❑ RPBS
2nd
Drug (Generic Name)
157431
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
DOSE
Patient Name
1st
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
Medication (Use Generic Name) Print
Date
Date
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
(✓) Appropriate box
PHARMACY PRESCRIPTION
1st
❑ PBS
❑ RPBS
2nd
PHARMACY PRESCRIPTION
Patient Name
1st
AS REQUIRED “PRN” MEDICATIONS
D
A
T
E
DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly DOCTOR: Please Press Firmly Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath Pharmacy Prescriptions underneath
Year 20
Date
Patient Name
1st
T
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D
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S
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R
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D
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I
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N
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Hourly
Frequency
PRN
Brand substitution not permitted
Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Quantity
Discharge
Required
Date
Patient Name
1st
Yes / No
Duration/
Qty
DR
Initials
MEDICATION CHART
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Hourly
Frequency
PRN
Brand substitution not permitted
Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Date
Patient Name
1st
Quantity
Discharge
Required
Yes / No
Duration/
Qty
DR
Initials
Discharge
Required
Yes / No
Duration/
Qty
DR
Initials
Discharge
Required
Yes / No
Duration/
Qty
DR
Initials
Discharge
Required
Yes / No
Duration/
Qty
DR
Initials
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Hourly
Frequency
PRN
Brand substitution not permitted
Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Date
Patient Name
1st
Quantity
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Hourly
Frequency
PRN
Brand substitution not permitted
Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Date
Patient Name
1st
Quantity
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Route
Dose
Hourly
Frequency
PRN
Brand substitution not permitted
Prescriber Name
Prescriber No.
Prescriber Signature
Contact
Indication
Pharmacy
Repeats
Quantity
REMOVE
THIS
SECTION
PRIOR
TO USE
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
Date
Patient Name
1st
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
Prescriber Signature
Medicare Australia/DVA copy Valid for use as PBS at: Ramsay
Private Hospital
Patient Name
1st
Dose
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Medicare Australia/DVA copy Valid for use as PBS at: Ramsay
Private Hospital
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Medicare Australia/DVA copy Valid for use as PBS at: Ramsay
Private Hospital
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Medicare Australia/DVA copy Valid for use as PBS at: Ramsay
Private Hospital
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
MEDICATION CHART
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Route
Dose
Prescriber Signature
Medicare Australia/DVA copy Valid for use as PBS at: Ramsay
Private Hospital
Quantity
Hourly
Frequency
PRN
Contact
Repeats
PHARMACY
PRESCRIPTION
REMOVE
THIS
SECTION
PRIOR
TO USE
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
PHARMACY PRESCRIPTION
Date
Patient Name
1st
PBS
RPBS
2nd
( ) Appropriate box
Drug (Generic Name)
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
Prescriber Signature
Pharmacist/Patient copy - Valid
for use with PBS Repeat
Authorisation
Patient Name
1st
Dose
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid
for use with PBS Repeat
Authorisation
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid
for use with PBS Repeat
Authorisation
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
Date
Route
1st
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid
for use with PBS Repeat
Authorisation
Patient Name
Quantity
Hourly
Frequency
PRN
Contact
PBS
RPBS
2nd
Tick if
Slow
release
Brand substitution not permitted
Prescriber Name
Prescriber No.
Indication
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Repeats
( ) Appropriate box
Drug (Generic Name)
MEDICATION CHART
Repeats
( ) Appropriate box
Drug (Generic Name)
PHARMACY
PRESCRIPTION
Route
Dose
Prescriber Signature
Pharmacist/Patient copy - Valid
for use with PBS Repeat
Authorisation
Quantity
Hourly
Frequency
PRN
Contact
Repeats
PHARMACY
PRESCRIPTION
REMOVE
THIS
SECTION
PRIOR
TO USE