Medicare Sign Up pack sample

MEDICINE SCHEDULE* Patient’s Name: __________________________________________ MR Number______________________ Pharmacy Name:____________________________________ Phcy Phone:____________________________ Date ________________________ Address: _______________________________________ MD Name: ______________________________ MD ph:___________________________ N C O Date Ordered Fecha Medications Dose, Route, Frequency Medicinas, Dosis, Ruta, Frecuencia Breakfast Desayuno Lunch Almuerzo Dinner Comida Bedtime Acostarse Clasification Clasificación Side Effects Efectos D/C Date Alta Level of Understanding (Good Fair-Poor) Key To Side Effects / Guía de Efectos Secundarios A-Nausea/Vomiting F- Skin Rash/Urticaria K- Edema P- Bradycardia U- Anorexia Vómito Erupción de la piel Edema Bradicardia B- Constipation G- Headaches L- Diaphoresis Q- Tachycardia V- Malaise Estreñimiento Dolor de Cabeza Sudoración Taquicardia Malestar C- Diarrhea H- Dizziness M-Hemorrhage R- Tremors W- Dyspnea Z. Other (Otros) ____________________ _ __________ ______ Allergies /Alergias : ____________________________ _______ Other MD order Medication: ______________________________ refer med No.______________________________ N/A Diarrhea Mareos Hemorrageas Temblores Falta de Aire D- Hypertension I- Hypoglycemia N- Hematuria S- Tinitus X- Confusion Presión Alta Hypoglicemia Hematuria Zumbidos en oidos Y- Flushing/Blurred Vision Enrojecimiento/Visión borrosa E- Hypotension J- Hyperglycemia O- Dry Mouth T- Fluid/Electrolyte Presión Baja Hiperglicemia Thirst Boca seca/sed Imbalance Desbalance líquido Nurse Name:_____________________________ ____ 9 No Medication interaction (checked by the nurse) within the Patient’s medication schedule Medication Status: 9 Medication Regimen Completed/Reviewed/Reconciled 9 No Change 9 Order Obtained Nurse Signature:_____________________________ ____ Check if any of the following were identified : 9 Potential adverse effects /drug reaction 9 Ineffective drug therapy 9 Significant side effects 9 Significant drug interactions 9 Duplicate drug therapy 9 Non-Compliance with drug therapy Date: _______________ Care Coordination: 9 Physician 9 SN 9 PT 9 OT 9 ST 9 MSW 9 Aide 9 Other(specify): _________________________________ Reconciliation Reconciliation Reconciliation Update on: _________________ By: ________________ Update on: _________________ By: ________________ Update on: _________________ By: _______________ Actualizado/Reconciliado en Por * Part of Emergency/Disaster Plan DO NOT USE ABBREVIATION: U, IU, QD, Q.D., qd, q.d., QOD, Q.O.D., qod, q.o.d., >, <, @, cc, μg, MS, MSO 4 , MgSO 4 , trailing zero: X.0 mg, .X mg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Administered by: Patient Caregiver Nurse Physician sample