Inpatient-drug-prescription-chart - Inpatient prescription chart and administration record

Sep 20, 2026

Upload by Marry

Inpatient drug prescription chart and administration record template for documenting patient medication orders and administration. Includes patient identifiers, allergy and adverse drug reaction fields, admission details, chart number and weight/height, and VTE risk assessment date. Provides sections for once-only “STAT” medications, oxygen prescriptions with target SpO2, regular time-based medication rounds with doses and signatures, and as-required (PRN) medications with indication, route, dose, and administration responsibility.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Inpatient prescription chart details

Patient information and clinical fields

Once-only (STAT) medications

Oxygen prescription

Regular prescriptions

As required (PRN) medications

| INPATIENT PRESCRIPTION CHART AND ADMINISTRATION RECORD | | | | | | --- | --- | --- | --- | --- | | Surname | Hospital number | Allergies, sensitivities and adverse drug reactions
Signed:
Date: | | | | First name | Date of admission | | | | | Date of birth | Male / female | | | | | Responsible consultant | Hospital / ward | | | | | | | | Chart number: Of | Weight:
Height: | | VTE risk assessment date: | | | | | | ONCE ONLY MEDICATIONS (‘STAT’ DOSES) | | | | | | | --- | --- | --- | --- | --- | --- | | Date &
time | Medication name | Dose | Route | Prescriber (signature & contact) | Given by | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | OXYGEN PRESCRIPTION | | | | | | --- | --- | --- | --- | --- | | Date &
time | Dose (% or L/min) | Route (type of mask) | Target SpO2 | Prescriber (signature & contact) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | NOT FOR CLINICAL USE GEEKY MEDICS | REGULAR PRESCRIPTIONS | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | Date | | | | | | | | | | | | | | | | MEDICATION | | Time | Dose | | | | | | | | | | | | | | | Route | Signature | 06:00 | | | | | | | | | | | | | | | | Date | | 09:00 | | | | | | | | | | | | | | | | Pharmacy check | | 12:00 | | | | | | | | | | | | | | | | | | 18:00 | | | | | | | | | | | | | | | | | | 22:00 | | | | | | | | | | | | | | | | MEDICATION | | Time | Dose | | | | | | | | | | | | | | | Route | Signature | 06:00 | | | | | | | | | | | | | | | | Date | | 09:00 | | | | | | | | | | | | | | | | Pharmacy check | | 12:00 | | | | | | | | | | | | | | | | | | 18:00 | | | | | | | | | | | | | | | | | | 22:00 | | | | | | | | | | | | | | | | MEDICATION | | Time | Dose | | | | | | | | | | | | | | | Route | Signature | 06:00 | | | | | | | | | | | | | | | | Date | | 09:00 | | | | | | | | | | | | | | | | Pharmacy check | | 12:00 | | | | | | | | | | | | | | | | | | 18:00 | | | | | | | | | | | | | | | | | | 22:00 | | | | | | | | | | | | | | | | MEDICATION | | Time | Dose | | | | | | | | | | | | | | | Route | Signature | 06:00 | | | | | | | | | | | | | | | | Date | | 09:00 | | | | | | | | | | | | | | | | Pharmacy check | | 12:00 | | | | | | | | | | | | | | | | | | 18:00 | | | | | | | | | | | | | | | | | | 22:00 | | | | | | | | | | | | | | | NOT FOR CLINICAL USE GEEKY MEDICS | AS REQUIRED (PRN) MEDICATIONS | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | MEDICATION | | | | | | | | | | | | | | | Route | Signature | Date | | | | | | | | | | | | | Date | | Time | | | | | | | | | | | | | Indication | | Dose | | | | | | | | | | | | | | | Route | | | | | | | | | | | | | | | Given by | | | | | | | | | | | | | MEDICATION | | | | | | | | | | | | | | | Route | Signature | Date | | | | | | | | | | | | | Date | | Time | | | | | | | | | | | | | Indication | | Dose | | | | | | | | | | | | | | | Route | | | | | | | | | | | | | | | Given by | | | | | | | | | | | | | MEDICATION | | | | | | | | | | | | | | | Route | Signature | Date | | | | | | | | | | | | | Date | | Time | | | | | | | | | | | | | Indication | | Dose | | | | | | | |

FAQs

What patient information is captured on the inpatient prescription chart?

The form records surname, first name, hospital number, date of admission, date of birth, sex, responsible consultant, hospital/ward, chart number, and weight/height. It also includes fields for allergies, sensitivities, and adverse drug reactions.

How are once-only (“STAT”) medications documented?

Once-only medications are recorded with date & time, medication name, dose, route, prescriber (signature & contact), and who gave the medication.

What information is required for PRN (as-required) medications?

PRN entries include medication, route, prescriber signature, date and time, indication, dose, route, and who administered it (given by).

Sep 20, 2026

Upload by Marry