B. List of Medications: Confidential (Including Over the Counter Medications) Prescribing To Be Given by: Physician *(Check Medications What Is It For? Dosage/Frequency How Is It Taken? Box If Physician (Self, Family, Staff, Delegation is Needed) CMA, CNA, Etc.) C. List of Treatments (e.g. Catherizations, Tube Feeding, Dressing Changes, Suctioning, Oxygen, Splints, Braces, Etc.) Prescribing Physician To Be Given by: *(Check Treatments What Is It For? Frequency How Is It Box If Physician (Self, Family, Staff, Performed? Delegation is Needed) CMA, CNA, Etc.)
B. List of Medications: (Including Over the Counter Medications) Confidential Medications What Is It For? Dosage/Frequency How Is It Taken? Prescribing Physician *(Check Box If Physician Delegation is Needed) To Be Given by: (Self, Family, Staff, CMA, CNA, Etc.) C. List of Treatments (e.g. Catherizations, Tube Feeding, Dressing Changes, Suctioning, Oxygen, Splints, Braces, Etc.) Treatments What Is It For? Frequency How Is It Performed? Prescribing Physician *(Check Box If Physician Delegation is Needed) To Be Given by: (Self, Family, Staff, CMA, CNA, Etc.)
SWPOC82610Numbered111615.docx