CARE DECISIONS COMMUNITY MEDICATION ADMINISTRATION RECORD If starting a syringe driver, use the All Wales Syringe Driver Chart Prescribe anticipatory end of life medication on this chart Remember the 4 Analgesic, Anti-emetic, Anxiolytic, Anti-secretory A’s: AS REQUIRED MEDICINES TIME DOSE/ GIVEN TIME DOSE/ GIVEN TIME DOSE/ GIVEN DATE DATE DATE ROUTE ROUTE ROUTE GIVEN BY GIVEN BY GIVEN BY INDICATION MEDICINE (Approved name) PAIN DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS DATE PRESCRIBER’S SIGNATURE INDICATION MEDICINE (Approved name) NAUSEA / VOMITING DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS DATE PRESCRIBER’S SIGNATURE INDICATION MEDICINE (Approved name) ANXIETY / DISTRESS DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS DATE PRESCRIBER’S SIGNATURE INDICATION MEDICINE (Approved name) SECRETIONS DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS DATE PRESCRIBER’S SIGNATURE
CARE DECISIONS COMMUNITY MEDICATION ADMINISTRATION RECORD If starting a syringe driver, use the All Wales Syringe Driver Chart Prescribe anticipatory end of life medication on this chart Remember the 4 A’s: Analgesic, Anti-emetic, Anxiolytic, Anti-secretory AS REQUIRED MEDICINES DATE TIME GIVEN DOSE/ ROUTE GIVEN BY DATE TIME GIVEN DOSE/ ROUTE GIVEN BY DATE TIME GIVEN DOSE/ ROUTE GIVEN BY INDICATION PAIN MEDICINE (Approved name) DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS PRESCRIBER’S SIGNATURE DATE INDICATION NAUSEA / VOMITING MEDICINE (Approved name) DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS PRESCRIBER’S SIGNATURE DATE INDICATION ANXIETY / DISTRESS MEDICINE (Approved name) DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS PRESCRIBER’S SIGNATURE DATE INDICATION SECRETIONS MEDICINE (Approved name) DOSE ROUTE FREQUENCY MAX DOSE IN 24 HRS PRESCRIBER’S SIGNATURE DATE
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