PoC

FDA Medication:

Yes No

Medication Name:

Package Name:

Include Obsolete Meds:

Yes No

Route:

Dose:

Start Date:

End Date:

Status:

Infusion Flush Protocol with Medication

Withdraw and discard:

ml of blood before flush

ml before med

ml after med

Heparin:

ml units/ml

Frequency:

Comments:

Frequency Start:

How Often:

times

Every:

For:

Time(s):

Class:

Please select a medication

Purpose:

Hospice-Related Medication:

Yes No

Diagnosis (DX):

OTC:

Yes No

Physician:

Physician Name:

Pharmacy:

Pharmacy Name:

Pharmacy Phone:

Administered on:

Medication:

Package:

Oxygen:

LPM

Quantity:

Dose:

Infusion Flush Protocol with Medication

Withdraw and discard:

ml of blood before flush

ml before med

ml after med

Heparin:

ml units/ml

Infusion Flush Protocol without Medication

(Optional)

Withdraw and discard:

ml of blood before flush

Infuse:

ml before flush

Infuse:

ml of Heparin units/ml

Frequency:

Continuous Administration:

Continuous

Time(s):

Administered

Not Administered

Start Date:

You are documenting that the medication was administered outside of the scheduled administration timeframe. If this is inaccurate, please update prior to saving.

Start Time:

Stop Date:

Stop Time:

Administration Method:

Gravity
Pump, type:		Settings:
IV Push

Administered By:

Nurse
Patient
Caregiver

Comments:

This is a Continuous Oxygen medication and will remain listed under undocumented medications in case it needs to be documented against again during your visit. To review the history of the oxygen, please refer to the Administration History tab.
This is a PRN medication and will remain listed in the PRN medication tab in case it needs to be documented against again during your visit. To review the history of the PRN medication, please refer to the Administration History tab.

Start Date:

Stop Date:

Administered By:

Nurse
Patient
Caregiver

Add Medication Review

Date of Review:

Is the patient compliant with his/her current medication regimen?

Yes No

Does the patient demonstrate desired response to drug therapy?

Yes No

Is the patient exhibiting potential adverse effects?

Yes No

Is the patient experiencing any adverse drug reactions?

Yes No

Does the patient have any duplicate medications?

Yes No

Is the patient experiencing any significant side effects?

Yes No

Were any drug interactions identified in the patient’s medications?

Yes No

Drug Class:

Drug Name:

Non Drug:

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Disclaimer for use of MediSpan Drugs information

You must accept the disclaimer below to proceed. You need only accept this disclaimer once. Your acceptance is valid for all future use by you of the Drugs information provided by Medi-Span in this system.

The Drugs and related information is provided to you by Wolters Kluwer Health, Inc. through the use of their Medi-Span ("MediSpan") system. The MediSpan system and the system are separate products provided by separate entities. The System is a proprietary software system developed and owned by ContinuLink, LLC. ContinuLink is not involved in any way in determining the content of the MediSpan system. ContinuLink makes no representations or warranties whatsoever, express or implied, with respect to, and assumes no responsibility or liability of any kind for, the MediSpan system or any data or information contained thereon. The MediSpan system is intended for use by consumers of this information in the United States only.

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The MediSpan system does not endorse drugs, diagnose patients, or recommend therapy. The MediSpan system is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and provide consumers with drug specific information. Healthcare practitioners should use their professional judgment in using the information provided. The MediSpan system is not a substitute for the care provided by licensed healthcare practitioners and consumers are urged to consult with their healthcare practitioner in all instances. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient.

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Pharmacy ID:

Pharmacy Name:

Pharmacy Phone:

Oxygen:

LPM - LPM

Titrate

Delivery Method:

Delivery Method Description:

DME Vendor:

DME Vendor Phone:

Start Date:

Discontinue Date:

Diagnosis (DX):

Hospice-related Medication:

Yes No

Purpose/Comments:

Duration:

Duration Comments:

Delivery Method:

Quantity:

Unit/ML:

Start Date:

Discontinue Date:

Route:

Route Description:

Infusion Flush Protocol without Medication

(Optional)

Withdraw and discard:

ml of blood before flush

Infuse:

ml before flush

Infuse:

ml of Heparin units/ml

Frequency:

Frequency Start:

Comments:

How Often:

times every For:

Time(s):

Medication Profile

Medication
Administration
Review
Infusion
Oxygen
Pharmacy
Allergy

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Medications

CURRENT
DISCONTINUED
MAR
ADMINISTRATIONS
SETUPS
REVIEWS

Weekly Episode History

Undocumented Medications
Administration History

Weekly Episode History

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Infusions and Oxygen

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Oxygen

General

Pharmacies
MedBox

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Filled by:

How often:

INTERACTIONS AND ALLERGIES

Interactions
Allergies

Drug Allergies

Drug to Drug Interactions

Drug to Food Interactions

Adverse Drug Effects

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DARRAGH, BETH (1211215-1) - RN SOC on 10/14/2021

4334 Garstview Cir, Roanoke, VA 24018-3198

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Statement of Patient Rights/Responsibilities- IHC - Approved & Signed- Version 2

Signed By: Nagy, Traci / Date Signed: 10/18/2021

Approved By: Crump, Tasha / Date Approved: 10/18/2021

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Infusion Flush Protocol with Medication

Infusion Flush Protocol with Medication

Infusion Flush Protocol without Medication

Disclaimer for use of MediSpan Drugs information

Infusion Flush Protocol without Medication

Medication Profile

Medications

Infusions and Oxygen

General

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INTERACTIONS AND ALLERGIES

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