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ATTAC H ALE R T LAB E L HE R E ANDWHE R E INDIC ATE D INS IDE C HAR T
Signature
Signature
Pharmaceutical Benefits Entitlement Number
VALID TO
Medicare Number
/ /
VALID TO
/ /
ENTITLEMENT NUMBERS
REFER TO CARE PLAN ROUTINE
PHARMACY PARTICULARS
VACCINATIONS
Influenza Vac c ine - Date Las t G iven: / /
P neumococcal Vaccine - Date Las t G iven: / /
Tetanus Vac c ine - Date Las t G iven: / /
Hep A/ B Vac c ine - Date Las t G iven: / /
- Date Las t G iven: / /
- Date Las t G iven: / /
- Date Las t G iven: / /
S cheduled C hildhood Vaccine UTD Yes No
Phone No.
PRESCRIBER PARTICULARS
Phone No.
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Month: 20
Client’s Name D.O.B.
REGULAR MEDICATION ORDERS Times
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
Apply Medical Director Medication Adhesive Label
ClientNo.
ADR ALERT
Yes No (Circle)
IND
IVID
UA
L M
ED
ICA
TIO
N O
RD
ER
S 1
-8PA
CK
ED
ME
DIC
AT
ION
S SIGN IN THIS PANEL FOR ALLPACKED MEDICATION
SIGN FOR INDIVIDUALMEDICATION IN THE PANELS
BELOW
PAC
KE
D
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 1
Page 2
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 3
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 4
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 5
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 6
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 7
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 8
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
Page 9
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 10
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
PAC
KE
D
RE
GU
LAR
ME
DIC
AT
ION
S 1
Page 11
FOLD
ON
TH
IS L
INE
TO
US
E A
S A
12
MO
NT
H C
HA
RT
R egular Medic ation Adminis tration
MEDICATION NOTES
ADR ALERT
Yes No (Circle)
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
ME
DIC
AT
ION
Page 12
Client’s Name D.O.B.
REGULAR MEDICATION ORDERS 9 TO 17 Time
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
R egular Medic ation
Prescriber Signature
Prescriber Signature
Date
Stop Date
Dose
Route
Frequency
Apply Medical Director Medication Adhesive Label
1 2 3 4 5 6 157 8 9 10 11 12 13 14
ADR ALERT
Yes No (Circle)Month: 20
ClientNo.
Page 13
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 14
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 15
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 16
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 17
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 18
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 19
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 20
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
Page 21
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Page 22
Month: 20
1 2 3 4 5 6 157 8 9 10 11 12 13 14
RE
GU
LAR
ME
DIC
AT
ION
S 2
- (
SH
OR
T T
ER
M &
VE
RB
AL
OR
DE
RS
BA
CK
PA
GE
)
Page 23 R egular Medic ation Adminis tration
MEDICATION NOTES
ADR ALERT
Yes No (Circle)
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SHORT TERM MEDICATION ORDERS
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
Short Term Medication Dose DatesTimes
Route
Frequency
Dr Signature Start Date
Stop DateDr Signature
PRN (When Required) Medication Orders Date Time Qty. S ig. Date Time Qty. S ig.R eas on / Ins truc tionsPRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
PRN Medication
Doctors Signature
Doctors Signature
Date
Stop Date
Dose
Route
Frequency/ /
/ /
Max Dose / 24 Hours
ADR ALERT
Yes No (Circle)
Client’s Name D.O.B.
Month: 20
ClientNo.
Date Date Date Date Date DateS ig. S ig. S ig. S ig. S ig. S ig.Time Time Time Time Time TimeQty. Qty. Qty. Qty. Qty. Qty.
NOTE: To Cancel - Draw diagonal line through entry after 24 hours. If Doctor is usingCompact confirmation labels, insert label number in column provided
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
Date Doctor NameMedication
Time Dose Route Frequency
CTO No.
2nd Signatory
RN Signature
Doctor Signature
Time Time Time Time Time Time
Given By Given By Given By Given By Given By Given By
ADMINISTRATION
VERBAL / TELEPHONE ORDERS - VALID FOR 24 HOURS ONLY
UNITS OF MEASURE AND CONCENTRATIONgram(s) gInternational unit(s) international unit(s)unit(s) unit(s)litre(s) Lmilligram(s) mgmillilitre(s) mLmicrogram(s) microgram, microgpercentage %millimole mmol
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