MEDICATION ADMINISTRATION RECORD
MEDICATION ADMINISTRATION RECORD
Name: _______________________________________ DOB: __________ Month _____________ Year 20____
Allergies:
Guardian name: Guardian phone:
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Initials _______ Signature _____________________ initials _______ Signature _________________________
Initials _______ Signature _____________________ initials _______ Signature _________________________
Note PRNs and medication errors on reverse page ___ of ____
PRNs and Medication Errors
|Date |Time |Initials |Medication |Dose |Explanation |Result |
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|1 |2 |3 |4 |5 |6 |7 |8 |9 |10 |11 |12 |13 |14 |15 |16 |17 |18 |19 |20 |21 |22 |23 |24 |25 |26 |27 |28 |29 |30 |31 | |Temp.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Pulse
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Resp.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Blood Press.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Weight
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
page ___ of ____
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