Medications – Billie Rubin DOB 06/15/1967
Medication Administration Record
Rubin: Billie DOB 06/15/1965
| DATE: | today – Day 2 post op | |||||||
| Time | Given/ Initials | |||||||
| SCHEDULED MEDICATIONS | ||||||||
| Acetaminophen 650 mg PO q4h | 0200 0600 1000 1400 1800 2200 | YU YU | ||||||
| Heparin 5000 units SC q12h until discharge | 0900 2200 | |||||||
| Insulin Aspart 4 units breakfast, lunch, supper | 0830 1230 1730 | |||||||
| Insulin Correction ISF #4 Aspart breakfast, lunch , supper | 0830 1230 1730 | |||||||
| Insulin NPH 6 units breakfast and bedtime | 0830 2200 | |||||||
| Magnesium hydroxide laxative 30 ml PO BID start Day 2 (hold if diarrhea) | 0900 2200 | |||||||
| PRN MEDICATIONS | ||||||||
| Antacid 10-30ml PO q1h PRN for gastric reflux | ||||||||
| Dimenhydrinate 12.5-50 mg PO or IV q4h PRN for nausea | ||||||||
| Diphenhydramine 25 mg PO or IV q2h PRN for pruritis | ||||||||
| Fentanyl 2mcg/ml & Bupivacaine 0.125% epidural infusion 3-8 ml/hr. *discontinue day 3 post op without weaning when patient can be managed on oral analgesics* | 1930-0730 | YU 3ml/hr | ||||||
| Fentanyl 25 – 100 mcg q1h prn epidural *discontinue day 3 post op without weaning when patient can be managed on oral analgesics* | 0200 | YU 50mcg | ||||||
| Ketorolac 30 mg IVq12h PRN adjunct analgesia | ||||||||
| Naloxone 0.1 mg IV q3h PRN pruritis | ||||||||
| Ondansetron 4mg PO or IV q4h prn nausea & vomiting | ||||||||
| IV FLUID (Type/Rate) | Start | End | ||||||
| D5 1/2 NS + 20mEq/L KCl @ 75cc/hr – day 1 IV TKVO if drinking well (1200-1500 mL/ 24 hours – day 2 saline lock IV when tolerating diet | 1930 | YU | ||||||
Previous MAR
Rubin: Billie DOB 06/15/1965
| DATE: | yesterday – Day 1 post op | |||||||
| Time | Given/ Initials | |||||||
| SCHEDULED MEDICATIONS | ||||||||
| Acetaminophen 650 mg PO q4h | 0200 0600 1000 1400 1800 2200 | YU YU TR TR TR YU | ||||||
| Heparin 5000 units SC q12h until discharge | 0900 2200 | TR YU | ||||||
| Insulin Aspart 4 units breakfast, lunch, supper | 0830 1230 1730 | TR TR YU | ||||||
| Insulin Correction ISF #4 Aspart breakfast, lunch , supper | 0830 1230 1730 | TR TR TR | ||||||
| Insulin NPH 6 units breakfast and bedtime | 0830 2200 | TR YU | ||||||
| Magnesium hydroxide laxative 30 ml PO BID start Day 2 (hold if diarrhea) | 0900 2200 | TR YU | ||||||
| PRN MEDICATIONS | ||||||||
| Antacid 10-30ml PO q1h PRN for gastric reflux | ||||||||
| Dimenhydrinate 12.5-50 mg PO or IV q4h PRN for nausea | ||||||||
| Diphenhydramine 25 mg PO or IV q2h PRN for pruritis | ||||||||
| Fentanyl 2mcg/ml & Bupivacaine 0.125% epidural infusion 3-8 ml/hr. *discontinue day 3 post op without weaning when patient can be managed on oral analgesics* | 0730 1930 | TR YU | ||||||
| Fentanyl 25 – 100 mcg q1h prn epidural *discontinue day 3 post op without weaning when patient can be managed on oral analgesics* | ||||||||
| Ketorolac 30 mg IVq12h PRN adjunct analgesia | ||||||||
| Naloxone 0.1 mg IV q3h PRN pruritis | ||||||||
| Ondansetron 4mg PO or IV q4h prn nausea & vomiting | ||||||||
| IV FLUID (Type/Rate) | Start | End | ||||||
| D5 1/2 NS + 20mEq/L @ 75cc/hr – day 1 IV TKVO if drinking well (1200-1500 mL/ 24 hours – day 2 saline lock IV when tolerating diet | 0730 1930 | 1930 TR 0730 YU | ||||||
Best Possible Medication History
Rubin: Billie DOB 06/15/1965
| Source of Information: Patient Date: 1 day preop | ||||||||||
| Medication | DOSE | ROUTE | FREQUENCY | LAST TAKEN | Continue | Discontinue | Hold | |||
| Metformin | 500 mg | PO | BID | morning | —- | —- | SS | |||
| Provider Signature: | SSpot MD 012345 | |||||||||
