KeithRN
Clinic Record Number
Date
Name Gender Age Weight Mid-arm circumference (1-5 yrs) Color
Chief Complaint
Temp HR Resp BP Allergies
Triage Assessment
MD Assessment
Diagnosis
1.
2.
3.
Clinic Record Number
Date
Name Gender Age Weight Mid-arm circumference (1-5 yrs) Color
Chief Complaint
Temp HR Resp BP Allergies
Triage Assessment
MD Assessment
Diagnosis
1.
2.
3.
| Antibiotics | Topical ointments | Diabetes |
|Amoxicillin 250mg chew |Hydrocortisone 1% 30 gm tube |Glipizide 5mg: daily #30 |
|Cephalexin 500 mg tabs: qid x5d #20 |Clotrimazole 1% 30 gm tube |Metformin 1000mg: bid #30-60 |
|Fluconazole 150mg tabs: yeast:1x-#1 |Bacitracin ointment 1 gm packets | |
|Bactrim DS 800/160 mg: bid x3d #6 | |ENT |
|Azithromycin 250mg tabs: 2 tabs first day, 1 tab daily|GI |Lubricant eye drops |
|next 4 days #6 |Calcium carbonate 500mg chew:prn #20 |Antibiotic eye drops |
| |Omeprazole 20mg:qd am #20 | |
|Anti-amebics |Promethazine 25mg tabs every 4 hours as needed #10 |Vitamins |
|Metronidazole 250mg:tid x7d #21 | |Childrens chew: daily #30 |
| |Analgesics |Pre-natal: daily #60 |
|Anti-helmentics |Acetaminophen 500mg:q4h prn #20 |Adult vitamins w/fe: daily #30 |
|Albendazole 400mg chew: 1x #1 |Ibuprofen 200mg: 2 tabs prn q6h #20 |Iron Sulfate 325 mg: daily #30 |
| |Naproxen Sodium 220mg tabs q12h #20 | |
|Anti-malarials | |Misc. |
|Hydroxychloroquine sulfate 200mg #9 |Respiratory |Diphenhydramine 50mg tabs |
| |Albuterol 2.5 mg-3 mL nebulizer sol. | |
|Anti-lice |Diphenhydramine 50 mg: prn q4h #10 |Other |
|Ivermectin 6mg: 2 tabs 1x #2 | | |
| |Cardiac | |
|Neuro-Anti-convulsant |HCTZ 25 mg: daily #30 | |
|Phenytoin sodium 100mg: 3 tabs gd #90 |Lisinopril 10 mg: daily #30 | |
| | | |
| | | |
| | | |
| Antibiotics | Topical ointments | Diabetes |
|Amoxicillin 250mg chew |Hydrocortisone 1% 30 gm tube |Glipizide 5mg: daily #30 |
|Cephalexin 500 mg tabs: qid x5d #20 |Clotrimazole 1% 30 gm tube |Metformin 1000mg: bid #30-60 |
|Fluconazole 150mg tabs: yeast:1x-#1 |Bacitracin ointment 1 gm packets | |
|Bactrim DS 800/160 mg: bid x3d #6 | |ENT |
|Azithromycin 250mg tabs: 2 tabs first day, 1 tab daily|GI |Lubricant eye drops |
|next 4 days #6 |Calcium carbonate 500mg chew:prn #20 |Antibiotic eye drops |
| |Omeprazole 20mg:qd am #20 | |
|Anti-amebics |Promethazine 25mg tabs every 4 hours as needed #10 |Vitamins |
|Metronidazole 250mg:tid x7d #21 | |Infant vitamins-liquid |
| |Analgesics |Childrens chew: daily #30 |
|Anti-helmentics |Acetaminophen 500mg:q4h prn #20 |Pre-natal: daily #60 |
|Albendazole 400mg chew: 1x #1 |Ibuprofen 200mg: 2 tabs prn q6h #20 |Adult vitamins w/fe: daily #30 |
| |Naproxen Sodium 220mg tabs q12h #20 |Iron Sulfate 325 mg: daily #30 |
|Anti-malarials | | |
|Hydroxychloroquine sulfate 200mg #9 |Respiratory |Misc. |
| |Albuterol 2.5 mg-3 mL nebulizer sol. |Diphenhydramine 50mg tabs |
|Anti-lice |Diphenhydramine 50 mg: prn q4h #10 | |
|Ivermectin 6mg: 2 tabs 1x #2 | |Other |
| |Cardiac | |
|Neuro-Anti-convulsant |HCTZ 25 mg: daily #30 | |
|Phenytoin sodium 100mg: 3 tabs gd #90 |Lisinopril 10 mg: daily #30 | |
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