URN:

Family name:
Not a valid prescription Approved pharmacy details:

Given names: unless identifiers present

Address: Pharmacy approval no:

Date of birth:
Medicare No:
Sex: M   F 
PBS/RPBS Entitlement No. Cut off section
 Concessional or dependent RPBS or   Safety Net Entitlement Card Holder
Safety Net Concession Card Holder
Attach ADR sticker
First prescriber to print patient name and check label correct:
See front page for details

As required PRN medicines Brand substitution not permitted   PBS/RPBS Year Hospital name Medication chart number of
Start Date Medicine (print generic name)/form Date
Additional charts
Hospital Provider number IV fluid BGL/insulin Acute pain Other
......  / ......

Continue on discharge?  Y  /  N
Ward Palliative care Chemotherapy IV heparin
Route Dose  and  hourly frequency PRN Time

days Qty:
Authority Prescription Number

Dispense?  Y / N
Indication Max PRN dose/24hr Dose Chart valid for:  1 month  4 months  12 months Initials:

Prescriber’s signature:
SAC/AAN Pharmacy Route
Once only and nurse initiated medicines and pre-medications/Telephone orders

Duration:
Prescriber signature Sign
Check initials Prescriber/ Prescriber Record of administration

Date:
Date/time Medicine /nurse
Route Dose Frequency nurse initiator Date Time/ Time/ Time/ Time/ Pharmacy
prescribed (print generic name)/form initiator
Start Date Medicine (print generic name)/form Date N1 N2 name Given by Given by Given by Given by
sign
......  / ......

Continue on discharge?  Y  /  N
Route Dose  and  hourly frequency PRN Time

days Qty:
Dispense?  Y / N

DO NOT WRITE IN THIS BINDING MARGIN

DO NOT WRITE IN THIS BINDING MARGIN

Indication Max PRN dose/24hr Dose

Prescriber’s signature:
SAC/AAN Pharmacy Route

Duration:
Prescriber signature Sign

Date:
Start Date Medicine (print generic name)/form Date
......  / ......

Continue on discharge?  Y  /  N
Route Dose  and  hourly frequency PRN Time

days Qty:
Dispense?  Y / N
Indication Max PRN dose/24hr Dose

PBS Hospital Medication Chart A (Acute)

Prescriber’s signature:
SAC/AAN Pharmacy Route

Duration:
Prescriber signature Sign

Date:
Start Date Medicine (print generic name)/form Date
......  / ......
Continue on discharge?  Y  /  N

Route Dose  and  hourly frequency PRN Time Medicines taken prior to presentation to hospital

PBS Hospital Medication Chart A (Acute) – 1 July 2016 – © Commonwealth of Australia 2016 – Version 1
(Prescribed, over the counter, complementary)
days Qty:
Dispense?  Y / N

Indication Max PRN dose/24hr Dose Own medicines brought in?  Y   N    Administration aid (specify) 
Prescriber’s signature:

Medicine Dose and frequency Duration Medicine Dose and frequency Duration
SAC/AAN Pharmacy Route
Duration:

Prescriber signature Sign

Date:

Start Date Medicine (print generic name)/form Date

......  / ......
Continue on discharge?  Y  /  N

Route Dose  and  hourly frequency PRN Time

days Qty:
Dispense?  Y / N

Indication Max PRN dose/24hr Dose

Prescriber’s signature:

GP: Community pharmacy:

SAC/AAN Pharmacy Route
Sign:   Print:    Date:    Medicines usually administered by: 
Duration:

Prescriber signature Sign

Date:

Prescriber Details
Start Date Medicine (print generic name)/form Date
Prescriber 1 Prescriber 2 Prescriber 3 Prescriber 4 Prescriber 5 Prescriber 6
......  / ......
Route Dose  and  hourly frequency PRN Time Name:
Continue on discharge?   Y / N

days Qty:

Prescriber No.
Indication Max PRN dose/24hr Dose
Prescriber’s signature:

Contact No.
Dispense?   Y / N

SAC/AAN Pharmacy Route

Address:
Duration:

Prescriber signature Sign

Date:

Signature: Signature Signature Signature Signature Signature Signature

Pharmaceutical review: Date: Date Date Date Date Date Date

Check if patient has another medication chart Check if patient has another medication chart
SAQ246_0_WholePBSChart_v12_A_FILM.indd 1 13/05/2016 11:46 AM
 Affix patient identification label here and overleaf
Attach ADR sticker URN:
Family name:
Not a valid prescription
Allergies and adverse drug reactions (ADR) Given names: unless identifiers present
Nil known   Unknown (tick appropriate box or complete details below) Address:
Medicine (or other) Reaction / type / date Initials

Cut off section Date of birth:

Medicare No:
Sex: M   F 
PBS/RPBS Entitlement No.
 Concessional or dependent RPBS or   Safety Net Entitlement Card Holder
Safety Net Concession Card Holder

First prescriber to print patient name and check label correct:

Sign  Print  Date Weight (kg):   Height (cm):

Regular Medicines Brand substitution not permitted   PBS/RPBS Year Recommended

administration times Regular Medicines Brand substitution not permitted   PBS/RPBS Year
Guidelines only Date and month
Variable dose medicine Date and month
Morning Mane 0800 Prescriber to enter administration times
Start Date Medicine (print generic name)/form Drug level
Night Nocte 1800 or 2000 Start Date Medicine (print generic name)/form Tick if
......  / ...... slow

Continue on discharge?  Y  /  N

Continue on discharge?  Y  /  N
Time level Twice ......  / ...... release
taken BD 0800 2000
Route Frequency  Prescriber to enter dose times and individual dose a day
Route Dose  and Frequency and now enter times 

days Qty:

days Qty:
Dose Three times
TDS 0800 1400 2000

Dispense?  Y / N

Dispense?  Y / N
a day

Prescriber’s signature:

Prescriber’s signature:
Regular
Indication Pharmacy Prescriber 6 hrly 0600 1200 1800 2400
6 hourly Indication Pharmacy
Regular
8 hrly 0600 1400 2200
Time to 8 hourly
be given Four times

Duration:

Duration:
Prescriber signature SAC/AAN QID 0600 1200 1800 2200 Prescriber signature SAC/AAN
a day

Date:

Date:
Nurse
initial
Start Date Medicine (print generic name)/form Tick if
VTE risk assessed:  Yes    Prophylaxis not required   Contraindicated  Signature: Date: slow

Continue on discharge?  Y  /  N
......  / ...... release
Start Date Medicine (print generic name)/form SR = Sustained, modified
......  / ...... Route Dose  and Frequency and now enter times 

days Qty:
or controlled release

Dispense?  Y / N
formulation.

Prescriber’s signature:
Route Dose  and Frequency and now enter times 
Tick if
slow If scored tablet, then half Indication Pharmacy
release
can be given.
Indication Pharmacy

Duration:
VTE prophylaxis Dose must be swallowed Prescriber signature SAC/AAN

Continue on discharge?  Y  /  N

Date:
without crushing.
Prescriber SAC/AAN

days Qty:
Start Date Medicine (print generic name)/form Tick if

Dispense?  Y / N
slow

Continue on discharge?  Y  /  N
Prescriber’s signature:
......  / ...... release
Mechanical prophylaxis AM Warfarin education record
Route Dose  and Frequency and now enter times 

days Qty:
check
Patient educated by: 

Dispense?  Y / N

Prescriber’s signature:
Sign: 

Duration:
Signature / NI signature Print name PM
check Indication Pharmacy

Date:
Date: 
Patient supplied Warfarin book:

Duration:
Start Date Marevan / Coumadin INR Prescriber signature SAC/AAN
Warfarin Result Sign: 

Date:
......  / ...... Circle brand
Continue on discharge?  Y  /  N

Date: 
Dose
Route Prescriber to enter Target INR Range Start Date Medicine (print generic name)/form Tick if
mg mg mg mg mg mg mg mg mg mg
days Qty:

individual doses slow

Continue on discharge?  Y  /  N
......  / ......
Dispense?  Y / N

release
Prescriber
Prescriber’s signature:

Route Dose  and Frequency and now enter times 

days Qty:
Indication Pharmacy

Dispense?  Y / N
Initial 1

Prescriber’s signature:
18:00
Reason for not Indication Pharmacy
Duration:

Prescriber signature
Initial 2
administering
Date:

Duration:
Codes MUST be circled Prescriber signature SAC/AAN

Date:
Prescriber to enter administration times
Start Date Medicine (print generic name)/form Tick if
Absent   A
slow
Start Date Medicine (print generic name)/form Tick if
Continue on discharge?  Y  /  N

slow

Continue on discharge?  Y  /  N
......  / ...... release
......  / ...... release

Route Dose  and Frequency and now enter times 

Fasting   F
days Qty:

Route Dose  and Frequency and now enter times 

days Qty:
Dispense?  Y / N

Dispense?  Y / N
  L
Prescriber’s signature:

On leave

Prescriber’s signature:
Indication Pharmacy Indication Pharmacy
Not available – obtain
supply or contact prescriber   N
Duration:

Prescriber signature SAC/AAN

Duration:
Prescriber signature SAC/AAN
Date:

Date:
Refused – notify prescriber   R
Start Date Medicine (print generic name)/form Tick if Start Date Medicine (print generic name)/form Tick if
slow
Continue on discharge?  Y  /  N

slow

Continue on discharge?  Y  /  N
......  / ...... release Self administered   S ......  / ...... release

Route Dose  and Frequency and now enter times 

days Qty:

Route Dose  and Frequency and now enter times 

days Qty:
Dispense?  Y / N

  V

Dispense?  Y / N
Vomiting
Prescriber’s signature:

Prescriber’s signature:
Indication Pharmacy Indication Pharmacy
Withheld – enter reason in
clinical record
 W
Duration:

Prescriber signature SAC/AAN

Duration:
Prescriber signature SAC/AAN
Date:

Date:
SAC: Streamline Authority Code
Pharmaceutical review: AAN: Authority Approval Number Pharmaceutical review:

Check if patient has another medication chart Check if patient has another medication chart
SAQ246_0_WholePBSChart_v12_A_FILM.indd 2 13/05/2016 11:46 AM