Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND

Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Student’s Name: Baja, Joan R. BSN II-C Date:

SAMPLE MEDICATION RECORD FORM
Name : _Kim trp____ Hospital Record No. _
Allergies: None Ward & Bed No. : _

Initial Ord. Disc. Med. Dose. Freq. Rt. Hour Date

2/19/21

JRB 2/19/202 PARACETAMOL 12m

1 n
110mg q4
4am

8pm JRB

12nn JRB

4pm

8pm

JRB 2/19/202 CIPROFLOXACIN 8 am JRB

1
180mg TID
1 pm
IVP
6 pm

JRB 2/19/202 LORAZEPAM 8am JRB

1
5mg OD
IVP

Name Jan-June Descriptive Rating July-December Descrptive Ratin

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Initials Printed Name Title Initials Printed Name Title

JRB JOAN RAMOS BAJA NEUST SN’23

Initial Ord. Disc. Med. Dose. Freq. Rt. Hour Date

STAT/ONE TIME MEDS/PRE-OPS.

Date
Date Date Tim Date
Medication Time Give Init. Medication Init.
Ord. Ord. e Given
n

Name Jan-June Descriptive Rating July-December Descrptive Ratin

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

OMISSION RECORD
Omission Reason Omission Site of Injection
Date Time Date Time
1. Right Arm
2. Left Arm
3. Right Gluteal
4. Left Gluteal
5. Right Thigh
6. Left Thigh
7. Right Abdomen
8. Left Abdomen

Route of
Administration
By mouth
PO
Intramuscular
IM
Intravenous IV
Subcutaneous SC
Sublingual SL
Intradermal ID
Topical
TOP
Right Eye
OD
Left Eye
OS
Both Eyes
OU

SAMPLE INTRAVENOUS FLUID FORM

Medicine Nurse’s Initials

IV Fluid Duration of Flow Date Time
Added over Printed Name
Infusion Rate
S C DC S C DC

Name Jan-June Descriptive Rating July-December Descrptive Ratin

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

Name: Ward: Hosp. Record No. _

Legend: S - Started C- Consumed DC- Discontinued

SAMPLE INTAKE AND OUTPUT RECORD

Patient : Bambi Ward: Pediatric Hospital Record No: Time: 8:00 am
TIME Nurse’s Initials
INTAKE OUTPUT
over Printed Name
I.V. Others
6-2
Oral O.F. Others Urine Stool Gastric Vo
Shift Mainline Side drip
mit
6-7
63 mL
7-8
Joan R Baja
63 mL
8-9
Joan R Baja
63 mL
9-10
Joan R Baja
10-11 63 mL
11-12 63 mL
12-1 63 mL
1-2 63 mL
8 Hrs.

Name Jan-June Descriptive Rating July-December Descrptive Ratin

Transforming Communities through Science and Technology
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED

TOTAL
Nurse’s Initials
2-10 I.V. Others
Oral O.F. Others Urine Stool Gastric over Printed Name
Shift
Mainline Side drip
2-3
3-4
4-5
5-6
6-7
7-8
8-9
9-10
8 Hrs.
TOTAL
Nurse’s Initials
10-6 I.V. Others
Oral O.F Others Urine Stool Gastric over Printed Name
Shift
Mainline Side drip
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
8Hrs.
TOTAL
24 Hrs.
TOTAL TOTAL INTAKE TOTAL OUTPUT:

Nurse’s Initials over Printed Name: ___________________________ Date: ___________________

Name Jan-June Descriptive Rating July-December Descrptive Ratin

Transforming Communities through Science and Technology