Pt._________________ Room # ______ Dx __________________ Wt _____ lbs ____kg

Vital Signs: T_____ P_____ R _____ BP_______/_______

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________

Trade___________________________Generic________________________________

Major side effects________________________________________________________

Is this a safe dose? _____ Ordered dose___________ Safe Dose Range______________

Assessment _____________________________________________________________