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Medication Chart
Tangata Whaiora's must not access medications independently and medications must always be in the safe unless permission is given in writing from Apex Care management.
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Date Time
DD
/
MM
/
YYYY
Tangata Whaiora/Name
First
Last
Support Worker
First
Last
Allergies?
Medication
Frequency
Dose
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Medication
Dose
Frequency
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Medication
Frequency
Dose
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Date Time
DD
/
MM
/
YYYY
HH
:
MM
AM
PM
AM/PM
Administered by or refused
First
Last
Name
First
Last
Signature
Clear