Patient: Age: Hospital No.

Impression/Diagnosis: Attending Physician(s):

Allergy to:
Generic/Brand
Name &
Classification
(10%)
Dose, Strength &
Formulation
(10%)
Indication/Mechanisms of
Drug Action
(15%)
Adverse/Side Effects
Drug Interaction
(15%)
Nursing Responsibilities
(20%)
Rationale
(10%)
Client Teaching
(20%)
Generic:





Brand:






Classification:





Ordered:




Timing:




Duration:




Other forms: