Standing Orders for OTC Medications - Ariel Clinical Services
Standing Orders for OTC Medications
Client Name____________________________ Date of Birth ______________________ Drug Allergies___________________________ Height___________ Weight ___________
Symptom
Medication
Dose
Route Approved
Fever/Pain
Cough
Constipation, No stools for greater than 3 days Minor Skin Irritations/ Rashes
Fever/Pain
Diarrhea, Reoccurring watery stools
Tylenol/ Acetaminophen
Cough Drops
Ducolax Suppository
Hydrocortisone Topical Cream or Ointment 0.5%
Motrin/ Ibuprofen
Imodium/ Loperamide
325mg tabs, take 2 By every 6 hours as mouth needed
Take 1every 2 hours On
as needed
tongue
10mg Suppository, Rectally insert one, one time. May repeat in 4 days
Apply lightly to Topical affected area up to 3 times daily as needed
200mg tabs, take 2 By every 6 hours as Mouth needed
2mg tab, take 2 tabs By after the first loose Mouth stool, take 1 tab for each subsequent loose stool
Constipation/ Dry Hard Stools
Milk of Magnesia
Take 30mL at Bedtime, once per day as needed
By Mouth
Skin Abrasions/ Minor Cuts
Neosporin/ Triple antibiotic ointment
Apply lightly to affected area up to three times daily as needed
Topical
Indigestion/ Tums/ Calcium Heart Burn/ Carbonate Upset Stomach
500mg tablets, chew 2 tablets every 2 hours as needed
By Mouth, chew
Not Approved
Other Instructions
May use water based lubricant as needed. Ct in side lying position. Do not use on face or open sore(s)
Do Not Exceed 4 tabs in 24 hours, if diarrhea continues for more than 48 hours contact Doctor Follow with a full glass of water
Do not use more than 14 tablets in 24 hours. If using daily, notify Doctor
Please Note: Generic brands are acceptable for the non-prescription medication listed above. Please read all product labels carefully. These standing orders are for ages 12 and older only. Contact Physician with ongoing issues.
In the event of poisoning or suspected poisoning, call poison control immediately. Rocky Mountain Poison and Drug Center 1-800-222-1222.
Physician Signature: ____________________________________ Date:_____________________
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