Medication Chart

Name: Florence JonesDate of birth: 04/05/1925

Address: 3 Darby Place Mayberry

Contact no: 9333 1234

Doctor: Dr Alan TrudeauxDoctor’s contact no: 9333 3333

Medicare no: 8888 7777 22Pension no: 666633333Z

Doctor A Trudeaux

Pharmacist Swallowitz

Client Self Administers Yes Dr Signature A.Trudeaux

Allergies/Reactions Penicillin (Rash)

Drug Name /
Route
/ Instructions / B’fast / Lunch / Dinner / B’time / Dr Sign
Duride 60 mg Tab Isosorbide mononitrate / Oral / 1 morning / 1 / A.Trudeaux
Tritace 10mg Cap Ramipril / Oral / 1 daily / 1 / A.Trudeaux
Minax 100mg Tab Metoprolol Tartrate / Oral / 1 twice daily / 1 / 1 / A.Trudeaux
Iscover 75mg Tab Clopidogrel / Oral / 1 morning / 1 / A.Trudeaux
MS Contin 15mg / Oral / 1 twice daily / 1 / 1 / A.Trudeaux

Non Packed Medications

Drug Name /
Route
/
Instructions
/ 0600 / Lunch / 1800 / B’time / Dr Sign
Actilax Syrup Lactulose / Oral / 20 ml night / 20mls / A.Trudeaux
Diprosone 0.5mg/g Cream Betamethosone / Oral / Apply 3 x daily / A.Trudeaux

PRN Medications

Drug Name /
Route
/ Instructions for Use / Dr Sign
Coloxyl Tab Senna / Oral / Give 1 – 2 tablets at night as required if bowels not opened 2nd daily / A.Trudeaux
Serenace 0.5 mg Tab Haliperidol / Oral / Give 1 tablet 8 hourly as required if agitated / A.Trudeaux

Medications not to be crushed –Dissolved in water – Mixed in Food

Drug Name /
Route
/
Instructions
/ Dr Sign

Medications that require monitoring

Drug Name / Instructions / Dr Sign
Duride / Monitor for: Headaches, Light headedness / A.Trudeaux
MS Contin / Monitor for: Drowsiness, confusion / A.Trudeaux

Doctor: Alan Trudeaux Signature A.Trudeaux

Medication Signing Sheet{PART B}

Name: Florence Jones

Date of birth: 04/05/1925

Doctor: A Trudeaux

Pharmacist: Swallowitz

Allergies/reactions: nil known

Client self medicates: yes

You need to:

 sign in correct day and time when giving medications

  • write in number of medications given

 write appropriate drug administration code for medication not given

 complete a Medication Incident Form if medications not taken as prescribed

Regular and non packed medication signing sheet

Day / Date / 0600 / Breakfast / Lunch / Dinner / Bedtime
Mon / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Tues / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Wed / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Thur / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Fri / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Sat / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose
Sun / Sign / Sign / Sign / Sign / Sign
No./Dose / No./Dose / No./Dose / No./Dose / No./Dose

Note: PRN medication signing sheets on following pagePRN medication signing sheets

Drug Name

/ Coloxyl (Senna)
Route / Orally
Instructions / Give 1 – 2 tablets as required if bowels not opened 2nd daily
Day / Date / Time / No. given / Signature
Mon
Tues
Wed
Thur
Fri
Sat
Sun

Drug Name

/ Seranace (Haliperidol)
Route / Orally
Instructions / Give 1 tablet 8 hourly as required if agitated
Day / Date / Time / Signature / Time / Signature / Time / Signature
Mon
Tues
Wed
Thur
Fri
Sat
Sun

Grange Home CareMedication ChartPage1 of 3