Medical orders and Drug Chart

Name (Surname, Given Names) Age Drug Sensitivities File # Room # Page #

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

Date Time Fluid Volume Route Freq Signature Administered

Started Ended Initials Started Ended Initials Started Ended Initials Started Ended Initials

Started Ended Initials Started Ended Initials Started Ended Initials Started Ended Initials

Nursing Care: ☐ General care ☐ Vital signs per shift ☐ Vitals signs every ______ hrs
☐ Special care (describe) _________________________________________________________________________________________________________
Other Orders (labs/imaging/discontinue med/etc): _______________________________________________________________________________________________

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