Medication Chart

Name: Agnes Jean MacDonald Date of birth: 01/12/16

Medicare no: 6999 12345 6

Pension no: 9999999999Z

Doctor: A. Trudeaux

Pharmacist: Swallowitz

Client self administers: yes

Regular medicationsAllergies/reactions: nil known

Drug name /
Route
/ Instructions / B’fast / Lunch / Dinner / B’time / Dr Sign
Daonil 5mg Glibenciamide / Oral / 1 tablet morning / 1 / A. Trudeaux
Diabex 500mg Metformin / Oral / 1 tablet 3 times day / 1 / 1 / 1 / A. Trudeaux
Brufen 200mg Ibrufen / Oral / 1 tablet twice day / 1 / 1 / A. Trudeaux

Non packed medications

Drug name /
Route
/
Instructions
/ 0600 / Lunch / 1800 / B’time / Dr Sign
Timoptic 0.25% Timolol Maleate / Eye / 1 drop both eyes / 1 / 1 / A. Trudeaux
Sofradex 50mcg/ml Dexamethason / Ear / 1 drop both ears / 1 / 1 / 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
Panadol 500mg Panadol / Oral / Give 1- 2 tablets 4 – 6 hrs as required for pain. Do not give more than 8 tablets in 24 hrs. / 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

Doctor: Alan TrudeauxSignature A. Trudeaux

Medication Signing Sheet

Name: Agnes MacDonald{PART B}

Date of birth: 01/12/16

Room no: 3

Doctor: A. Trudeaux

Pharmacist: Swallowitz

Allergies/reactions: nil known

ClientSelf 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

/ Panadol (Paracetamol)
Route / Orally
Instructions / Give 1- 2 tablets 4 – 6 hourly as required for pain. Do not give more than 8 tablets in 24 hrs
Day / Date / Time / Signature / Time / Signature / Time / Signature
Mon
Tues
Wed
Thur
Fri
Sat
Sun

Grange Home CareMedication Signing SheetPage 1 of 3