Example of medical administration chart?

Date: _______________________

Patient Name: _______________________

DOB: _______________________

Medical Record Number: _______________________

Allergies: _______________________

Medication Name Dosage Route Frequency Time Given Initials

1. ________________________ ________________________ ________________________ ________________________ ________________________

2. ________________________ ________________________ ________________________ ________________________ ________________________

3. ________________________ ________________________ ________________________ ________________________ ________________________

4. ________________________ ________________________ ________________________ ________________________ ________________________

5. ________________________ ________________________ ________________________ ________________________ ________________________

6. ________________________ ________________________ ________________________ ________________________ ________________________

7. ________________________ ________________________ ________________________ ________________________ ________________________

8. ________________________ ________________________ ________________________ ________________________ ________________________

9. ________________________ ________________________ ________________________ ________________________ ________________________

10. ________________________ ________________________ ________________________ ________________________ ________________________

Notes: _______________________________________________________________

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Physician Signature: _______________________

Nurse Signature: _______________________

Medical Administration Chart for Patient Name

Date:

Patient ID:

Medication Name dose, route, frequency:

| Medication Name | Dose | Route | Frequency | Scheduled Time | Time Given | By |
|---|---|---|---|---|---|---|
| Acetaminophen 500 mg | 500 mg | PO | Every 4 hours | 08:00 | | |
| Hydrocodone 5 mg | 5 mg | IV | Every 4 hours | 12:00 | | |
| Albuterol inhaler | 2 puffs | Inhalation | Every 4 hours | 16:00 | | |
| Insulin NPH 10 units | 10 units | Subcutaneous | Daily | 18:00 | | |

Special Instructions:

- Acetaminophen to be given with food or milk.
- Hydrocodone to be given only for severe pain.

Monitoring:

- Monitor blood pressure every 2 hours.
- Monitor respiratory rate every hour.
- Monitor pain levels every 4 hours.

Assessment:

- Patient tolerance of medications
- Effectiveness of medications
- Any adverse reactions

Signature of Nurse:

Notes:

- This is just an example, and the specific medications, doses, routes, and frequencies will vary depending on the patient's individual needs.
- The chart should be updated every time a medication is given.
- The chart should be reviewed and signed by a nurse every shift.