SKILL STATION

Candidate Name: ________________________________________________

Please read this Insulin prescription chart carefully. You may refer to the brief during the assessment.

Scenario

Filled out on the day

All the equipment you need is provided. Please administer the __________ safely using the prescription below.
It is TODAY and it is xx:xx hours.
PATIENT DETAILS DRUG DOSE SIGNATURE
Name: xxxxxxxxxxx
Address: xxxxxxxxxxxxxx Signature:
MEDICATION
Town/City: xxxxxxxxxxxxxx TODAY at xx:xx hours
Dose
Post Code: xxx xxx Date:
Date of Birth: xx/xx/xxx
Batch Number:
ALLERGIES: Prescribers Signature: Time:
Signature (GP) Today xx:xx Signature (GP) Today 00:00
Nurses Notes:

Print Name: Signature and Date/ Time:

Version 1 20180620