of Chart Email DVA number

Fax Phone
Name Pension number
the chart is commenced PHARMACY Medicare number
4 months from the date
RACF Address
Review date ___/___/___ Maximum chart validity is
RACF Name Chart commenced ___/___/___ Expiry date ___/___/___ Other Y / N (specify):
Insulin Y/N
Signature Signature Variable dose Y / N
ALERT:Complexmedications
Email Email
Prescriber number Prescriber number
Out of hours Out of hours Non packed medicines
Fax Phone Fax Phone
Address Address
Name Name
PRESCRIBER details (if not primary GP) PRESCRIBER details (if not primary GP)
Details if Y to above:
Y/N Other
Signature Signature
Y/N Self administers
Email Email
Y/N Nil by mouth
Prescriber number Prescriber number
Y/N Resistive to medicine
Out of hours Out of hours
Y/N Dexterity difficulties
Fax Phone Fax Phone
Address Address Y/N Cognitive impairment
Name Name Y/N Swallowing difficulties

Front page MUST be sent to pharmacy on each change

PRESCRIBER details (if not primary GP) PRIMARY GENERAL PRACTITIONER CONSIDERATIONS
RACF name RACS ID
Y/N
IHI URN/MRN
name?
/ / Photo date Gender / / Date of Birth
photo withsimilar
Insert Preferred name Consumer MedicationChartv.4
ALERT
Consumer name
NationalResidential
page 1
Privacystatement
The information on this form, including your used to record details of an under co-payment to PBS Prescribers, the Department of Health
Medicare, Centrelink and/or Department prescription (where there is no entitlement to a and Ageing, Department of Veterans’ Affairs,
of Veterans’ Affairs number, will be used to payment of benefit under PBS or RPBS). With Centrelink, the Department of Human Services or
assess your entitlement to benefits under the your consent, the PBS approved supplier or as authorised or required by law. This information
Pharmaceutical Benefits Scheme (PBS) or the PBS Prescriber may store your details for use will be handled in accordance with the provisions
Repatriation Pharmaceutical Benefits Scheme on future prescriptions. The collection of this in the Privacy Act 1988 (Cth) (the PrivacyAct).
(RPBS) and to determine payments due to information is authorised by the National Health
approved suppliers. This information will also be Act 1953. This information may be disclosed
Furtherinformation
The National Residential Medication Further information may be obtained at
Chart (NRMC) was developed by the www.safetyandquality.gov.au
Australian Commission on Safety and or by emailing
Quality in Health Care (the Commission) [email protected]
to facilitate the direct supply and claiming
from a medication chart of most medicines
under the Pharmaceutical Benefits Scheme
(PBS) and Repatriation Pharmaceutical
Benefits Scheme (RPBS), and to define
national standards for medication charts in
residential care facilities.
page 52
 AllergiesandAdverse Consumer name
DrugReactions(ADR) Y/Nilknown
ALERT
Consumer Preferred name Insert
Drug(orother) Reaction/type/date
withsimilar
Date of Birth / / Gender Photo date / /
photo
name?
URN/MRN IHI
Y/N
Sign Print Date ___/___/___ RACS ID RACF name

W Withheld (clinical reason) S Sleeping C Contraindicated R Refused A Absent N Not available

Nutritionalsupplementintakeandweightmonitoring(under80kgs)
Start date Nutritional supplement Dose Weight progress Comments

Non packed
80kg 80kg
___/___/___
Route
Stop date
75kg 75kg
Valid for
duration
of chart Additional instructions Frequency
70kg 70kg
OR

Stop date
PBS/RPBS CTG 65kg 65kg
___/___/___
Brand substitution not permitted

Prescriber signature and name 60kg 60kg

Date of prescribing ___/___/___

Nutritionalsupplementdirections 55kg 55kg

(if ordered by dietician or registered nurse)
50kg 50kg

BMI
45kg 45kg
Reviewandevaluation
Intake
40kg 40kg
Enter amount of nutritional supplement taken per shift
as morning/lunch and afternoon/evening .
35kg 35kg
For example, one cup = 1 serve; half a cup = ½ serve;
one third cup = ¹⁄³ serve. 30kg 30kg
Name
Date Date Designation
Weightprogress
Week 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Week
Plot weight on chart by using a dot to indicate weight progress. Month1 Month2 Month3 Month4
page50
page 2

Prescribingandadministration

Forprescribers Commonlyusedabbreviations
PBS/RPBS: Strike through the option which does not apply. If private (non-PBS), inresidentialcare
strike out both PBS and RPBS.
Brandsubstitutionnotpermitted: Indicate if the specified brand must be supplied by ticking the box. Route
CTG: Closing the Gap PBS Co-payment initiative for registered Aboriginal and Torres Strait Islander people. If PO: per oral (via the mouth e.g. tablets)
applicable, tick the box.
PR: per rectum (via the rectum e.g. suppository for constipation)
Streamlinedauthoritycode: write the streamlined authority code in the spaces provided, where topical: per the skin (applied to the skin e.g. cream)
applicable. Streamlined authority codes are available at www.pbs.gov.au
subcut: subcutaneous (an injection into the upper skin layers e.g. insulin)
Remember:Certain PBS/RPBS medicines will still require a written prescription from
the prescriber, in addition to an order on the medication chart, including: subling: sublingual (under the tongue)

• all Authority required items requiring prior approval (including PBS/RPBS NG: nasogastric (via a specialised tubing inserted into the
items with increased quantities and/or repeats) nose e.g. nutritional supplements)
• all items only available under special arrangements (Section 100) PEG: percutaneous enteral gastrostomy (via a specialised tubing
• Controlled Drugs (Schedule 8 medicines). inserted into the stomach e.g. nutritional supplements)
IM: intramuscular (an injection into the muscle e.g. influenza vaccination)
IV: intravenous (a fluid inserted via an inserted line into a vein)
Thesixrightsof Abbreviationswhenmedicine
medicineadministration notadministered Frequency(suggestedtimesmostcommonlyusedinresidentialcare)
1 Right consumer mane: morning (e.g. breakfast)
W Withheld (clinical reason)
2 Right medicine nocte: night (e.g. dinner)
S Sleeping
3 Right dose C Contraindicated bd: twice per day (e.g. breakfast and dinner)
4 Right time R Refused tds: three times per day (e.g. breakfast, lunch and dinner)
5 Right route A Absent qid: four times per day (e.g. breakfast, lunch, dinner and bed time)
6 Right documentation N Not available

 ReasonforPRNAdministration Please refer to supplemental information provided within the NRMC user guides:

NRMC – NRMC –
At Agitation P Pain Nurse User Guide User guide for
prescribers
Ag Aggression Co Constipation
Ps Psychosis NV Nausea / Vomiting
H Hallucinations Z Sleep
Wa Wandering

page 51
 Prescriberchecklist

1 Consumer Identification Panel 2 Prescriber Information

  llergiesandAdverse
A Consumer name John Richard Brown PRIMARY GENERAL PRACTITIONER
DrugReactions(ADR) Y/Nilknown ALERT ThesefieldsMUSTbe
Drug(orother) Reaction/type/date Consumer Preferred name John Insert Name Dr Joseph Smith completedtobeavalid
withsimilar
Date of Birth 07/01/1935 Gender M Photo date 02/08/20
photo Address 123 Apple Avenue, Moree NSW 2063 prescription.Thisisoften
name?
URN/MRN L979797 IHI 289897248602
Phone 9123 4567 Fax 9123 4568 prepopulatedbythe
Y/N Out of hours 9123 4569 residentialcarefacility.
Sign Print Date ___/___/___ RACS ID 04123 RACF name Prescriber number X122334456
Email [email protected]
EachchartMUSTbe
Signature signedbytheprescriber.
ThesefieldsMUSTbecompletedfortheNRMCtobeavalid
prescription.Thisisoftenprepopulatedbytheresidentialcarefacility.

3 Essential Prescription Fields required for a valid prescription

All fields circled in RED must be completed by a prescriber to enable a pharmacist to supply and claim for a PBS/RPBS medicine.
All fields circled in GREEN are to be completed by the prescriber where applicable.

1
Start date 1. Medicine/form/strength Dose TheprescriberMUSTwritelegiblythe

Digoxin dose,route,frequencyandstrengthaswell

Non packed
01 01 21
___/___/___ asthemedicinenameasindicatedinthe
TheprescriberMUSTfillastartandindicate
astopstartdatebyeithertickingthevalidfor Stop date Oral liquid Route
prescriptionbox.

durationofchartorastopdate. Valid for

duration
of chart
PO
OR
Additional instructions Frequency
Stop date
___/___/___ 50 microg / ml daily
TheprescriberMUSTcompletethe
PBS/RPBS Streamlined authority code 3 6 3 2 2 streamlinedauthoritycodeformedicines
tobesuppliedasAuthorityRequired
CTG Brand substitution not permitted STREAMLINED.

Jo Smith
Prescriber signature and name TheprescriberMUSTcompletethisbox.
Date of prescribing ___/___/___
26 12 20

page
page50
2

Nutritional supplements daily intake record

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Start
weight initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

kg
initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Start
weight initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

kg
initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Start
weight initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

kg
initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Start
weight initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

kg
initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial initial

Newchartrequiredwithin2weeks
page 3
 Regularmedicine Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Signinthissection Times
for multi-dosedelivery
(eg. multi-dosepacks)

Month1
Breakfast

Lunch

Dinner
Signinthissection
forindividualmedicine Bed time
administration
Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1
Times

Start date 1. Medicine/form/strength Dose

Month1
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Prescription 2 on next page page484

page

InsulinPRN(asrequired)medicine
Start date Medicine/form/strength Dose Date
Non packed

units Time
___/___/___

Stop date Insulin Route Dose

units units units units units units units units units units units units units units units units units

Valid for
duration
order Initial

of chart Time Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
OR Max dose / 24 hr
Date
Stop date
PBS/RPBS Time
___/___/___ CTG
Dose
units units units units units units units units units units units units units units units units units

Prescriber signature and name Initial

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Start date Medicine/form/strength Dose Date

Non packed

units Time
___/___/___

Stop date Insulin Route Dose

units units units units units units units units units units units units units units units units units

Valid for
duration
order Initial

of chart Time Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
OR Max dose / 24 hr
Date
Stop date
PBS/RPBS Time
___/___/___ CTG
Dose
units units units units units units units units units units units units units units units units units

Prescriber signature and name Initial

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

page 49
 InsulinPRN(asrequired)medicine
Start date Medicine/form/strength Dose Date

Non packed
units Time
___/___/___

Stop date Insulin Route Dose

units units units units units units units units units units units units units units units units units

Valid for
duration
order Initial

of chart Time Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
OR Max dose / 24 hr
Date
Stop date
PBS/RPBS Time
___/___/___ CTG
Dose
units units units units units units units units units units units units units units units units units

Prescriber signature and name Initial

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Start date Medicine/form/strength Dose Date

Non packed

units Time
___/___/___

Stop date Insulin Route Dose

units units units units units units units units units units units units units units units units units

Valid for
duration
order Initial

of chart Time Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
OR Max dose / 24 hr
Date
Stop date
PBS/RPBS Time
___/___/___ CTG
Dose
units units units units units units units units units units units units units units units units units

Prescriber signature and name Initial

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

page
page484

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month1
page 5
 Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
page46
page 6

Each prescribing box below is to be used for Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
one insulin dose-time only Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Start date Medicine/form/strength Dose

Time Time
units
Non packed

___/___/___

Insulin Route

order
Stop date Dose Dose
Valid for
Time units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration
duration
of chart
OR Initial1 Initial1
PBS/RPBS
Stop date CTG

___/___/___ Prescriber signature and name Initial2 Initial2

Date of prescribing ___/___/___

Start date Medicine/form/strength Dose

Time Time
units
Non packed

___/___/___

Insulin Route

order
Stop date Dose Dose
Valid for
Time units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration
duration
of chart
OR Initial1 Initial1
PBS/RPBS
Stop date CTG

___/___/___ Prescriber signature and name Initial2 Initial2

Date of prescribing ___/___/___

Start date Medicine/form/strength Dose

Time Time
units
Non packed

___/___/___

Insulin Route

order
Stop date Dose Dose
Valid for
Time units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration
duration
of chart
OR Initial1 Initial1
PBS/RPBS
Stop date CTG

___/___/___ Prescriber signature and name Initial2 Initial2

Date of prescribing ___/___/___

Check for PRN dose Newchartrequiredwithin2weeks page 47

Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

BGLprogress
20+
20
19
18
17
16

Chart
15
14
13 B
12 G

Bloodglucoselevel L
11
10
9
8
7
6
5
4
3
2
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

page
page46
6

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month2
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
page 7
 Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
page44
page 8

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

page 45
Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

BGLprogress
20+
20
19
18
17
16

Chart
15
14
13 B
12 G

Bloodglucoselevel L
11
10
9
8
7
6
5
4
3
2
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

page
page44
8

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month3
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
page 9
 Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4 Newchartrequiredwithin2weeks
page
page 42
10

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

page 43
 Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

Bloodglucoselevel
Time

BGL

BGLprogress
20+
20
19
18
17
16

Chart
15
14
13 B
12 G

Bloodglucoselevel L
11
10
9
8
7
6
5
4
3
2
1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

page
page 42
10

Regularmedicine Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2
Times

Start date 2. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Times

3
Start date 3. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Newchartrequiredwithin2weeks
Prescription 4 on next page

page 11
 Regularmedicine Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Times

4
Start date 4. Medicine/form/strength Dose

Month1
Non packed
___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Times

5
Start date 5. Medicine/form/strength Dose

Month1
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Prescription 6 on next page

page 12
40

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

Time

Dose
units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units units

Insulinadministration Initial1

Initial2

page 41
 Insulinandbloodglucoselevel(BGL)recording
Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
BGLinstructions 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Date Date

Bloodglucoselevel
Frequency Time Time

BGL BGL

Bloodglucoselevel
Time Time

Contact prescriber if BGL above________ mmols BGL BGL

Contact prescriber if BGL below________ mmols

Bloodglucoselevel
Time Time
Prescriber signature
BGL BGL

BGLrecording BGLprogress
20+ 20+
Write the time taken and the BGL in the space
20 20
provided under the correct date. You may record
19 19
up to 3 BGLs per day if required by prescriber.
18 18
17 17
BGLprogress 16 16

Chart
Plot BGL on chart by using a dot to indicate 15 15
14 14
BGL progress. You may plot up to three
BGLs per day if required. B 13 13 B
G 12 12 G
L
Bloodglucoselevel L
11 11
10 10
Comments 9 9
8 8
7 7
6 6
5 5
4 4
3 3
2 2
1 1
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date

40
page 12

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month1
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month1
page 13
 Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month2
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
14
page 38

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Pathology result

Variabledose
Doseprescribed

Dosegiven

Time

Initial 1

Initial 2

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Pathology result

Variabledose
Doseprescribed

Dosegiven

Time

Initial 1

Initial 2

Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Pathology result

Variabledose
Doseprescribed

Dosegiven

Time

Initial 1

Initial 2
Newchartrequiredwithin2weeks
page 39
 Variabledosemedicine*(notinsulin)e.g.Warfarin
*ThispagetobeusedtoprescribedifferentstrengthsofONEmedicineonly
Medicine/form/strength Dose Medicine/form/strength Dose Medicine/form/strength Dose
Start date Non packed Start date Start date Instructions

Non packed

Non packed
___/___/___ ___/___/___ ___/___/___ Pathology frequency

Stop date Variable Route Stop date Variable Route Stop date Variable Route
Valid for
duration dose Valid for
duration dose Valid for
duration dose
order order order
of chart of chart of chart
OR OR OR
Frequency Frequency Frequency
Stop date Stop date Stop date Contact prescriber if pathology
Additional instructions Additional instructions Additional instructions
___/___/___ ___/___/___ ___/___/___ results are outside range of______________

Contact prescriber if result is above________

PBS/RPBS Streamlined authority code PBS/RPBS Streamlined authority code PBS/RPBS Streamlined authority code
CTG Brand substitution not permitted CTG Brand substitution not permitted CTG Brand substitution not permitted Contact prescriber if result is below________

Prescriber signature and name Prescriber signature and name Prescriber signature and name
Prescriber signature
Date of prescribing ___/___/___ Date of prescribing ___/___/___ Date of prescribing ___/___/___

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Pathology result

Variabledose
Doseprescribed

Dosegiven

Time

Initial 1

Initial 2

page 38
14

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1
Month2
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
page 15
 Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month3
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
16
page 36

Phoneorder
Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

page 37
 Phoneorder
Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

Medicine Dose Reason ordered Date

Time
Route Additional instructions Dose
Frequency Initial

Start date ___/___/___ Signature 1 Date ___/___/___ Date

Time
Strength Stop date ___/___/___ Signature 2 Date ___/___/___
Dose
Prescriber name Prescriber signature Date ___/___/___ Initial

16
page 36

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month3
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
page 17
 Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4 Newchartrequiredwithin2weeks
page
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18

Nurseinitiatedmedicine
Medicine Dose Date

Time

Dose
Route
Indication Initial

Date

Time
Date Frequency
Dose
___/___/___ RN signature and name
Initial

Medicine Dose Date

Time

Dose
Route
Indication Initial

Date

Time
Date Frequency
Dose
___/___/___ RN signature and name
Initial

Medicine Dose Date

Time

Dose
Route
Indication Initial

Date

Time
Date Frequency
Dose
___/___/___ RN signature and name
Initial

page 35
 PRN(asrequired)medicine
Start date Medicine/form/strength Dose Date

Non packed
Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Frequency
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Start date Medicine/form/strength Dose Date

Non packed

Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Frequency
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Reason for PRN Administration key on page 51.

page
page 34
18

Regularmedicine Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

6
Times

Start date 6. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Times

7
Start date 7. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Newchartrequiredwithin2weeks
Prescription 8 on next page
page 19
 Regularmedicine Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

8
Date
Times
Start date 8. Medicine/form/strength Dose Time

Month1
Non packed
___/___/___ Dose

Stop date Route Initial

Valid for
duration Reason
of chart
OR
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Additional instructions Frequency
Stop date Date
___/___/___ Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Date
Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Times

9
Start date 9. Medicine/form/strength Dose Time

Month1
Non packed

___/___/___ Dose

Stop date Route Initial

Valid for Reason
duration
of chart
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
OR
Additional instructions Frequency
Stop date Date
___/___/___ Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Prescription 10 on next page Reason for PRN Administration key on page 51.
page
page 20
32

PRN(asrequired)medicine
Start date Medicine/form/strength Dose Date
Non packed

Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Nocte
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Start date Medicine/form/strength Dose Date

Non packed

Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Nocte
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Reason for PRN Administration key on page 51.

page 33
 PRN(asrequired)medicine
Start date Medicine/form/strength Dose Date

Non packed
Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Frequency
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Start date Medicine/form/strength Dose Date

Non packed

Time
___/___/___
Dose
Stop date Route
Initial
Valid for
duration
of chart Reason
OR
Indication
Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Frequency
Stop date Date
___/___/___ Max dose / 24 hr Time

PBS/RPBS Streamlined authority code Dose

CTG Brand substitution not permitted Initial

Prescriber signature and name Reason

Date of prescribing ___/___/___ Effective Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Reason for PRN Administration key on page 51.

page 20
page 32

Month1: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month1
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month1
page 21
 Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month2
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
page 22
30

Shorttermmedicine
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

page 31
 Shorttermmedicine
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times

Non packed
___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Medicine/form/strength Dose Date

Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

30
page 22

Month2: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month2
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month2
page 23
 Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month3
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
page 24
28

Shorttermmedicine
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

page 29
 Shorttermmedicine
Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times

Non packed
___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

Month: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Medicine/form/strength Dose Date
Start date Times
Non packed

___/___/___
Route

Stop date

Additional instructions Frequency

___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___

28
page 24

Month3: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2
Month3
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month3
page 25
 Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month4 Newchartrequiredwithin2weeks
page 26

Regularmedicine Month4: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

10
Times

Start date 10. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

11
Times

Start date 11. Medicine/form/strength Dose

Month4
Non packed

___/___/___

Stop date Route

Valid for
duration
of chart
OR
Additional instructions Frequency
Stop date
___/___/___

PBS/RPBS Streamlined authority code

CTG Brand substitution not permitted

Prescriber signature and name

Date of prescribing ___/___/___
Checkifconsumerhasanothermedicationchart Newchartrequiredwithin2weeks

page 27