Medical orders and Drug Chart

Name (Surname, Given Names) Age Drug Sensitivities File # Date: (d/m/y) Page #

Diet: ☐ Nothing by mouth ☐ Clear Liquids ☐ Full liquid ☐ Soft ☐ Regular ☐ Low salt ☐ Low protein ☐ Low fat ☐ Diabetic Diet
☐ Other (describe) _________________________________________________________________________________________________________________

Parenteral Fluids

# Date Time Fluid Volume Freq Signature Administered

Started Ended Initials Started Ended Initials Started Ended Initials Started Ended Initials
1
Started Ended Initials Started Ended Initials Started Ended Initials Started Ended Initials
2

Medication Dosage In solution # Pharmacy Medication Dosage In solution # Pharmacy

Nursing Care: ☐ General care ☐ Vital signs per shift ☐ Vitals signs every ______ hrs ☐ Other ______________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
☐ Special care (describe) ________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Other Orders (labs/imaging/discontinue med/etc): ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
 Medical orders and Drug Chart
Medications

Date Time Active ingredient * Dose Route Freq Signature Administered Pharmacy
Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Time

Signature

Single Dose Medications

Administered
Date Time Active ingredient * Dose Route Signature Pharmacy
Time Signature

* if specific brand is required, use brand name instead of active ingredient