Medication charts for hospitals and residential care facilities

A medication chart is a form of prescription used to:

• direct the supply and administration of S4 or S8 medicines in public and private hospitals
• direct the supply of S4 or S8 medicines to patients on discharge
• record medicines used in the treatment of patients in hospital.

A residential care chart is a form of prescription used to:

• direct the supply and administration of S4 medicines
• direct administration of S8 medicines
• record medicines used in the treatment of patients in residential care facilities.

Residential care charts cannot be used to direct supply of S8 medicines. Any S8 medicines to be supplied by a pharmacy to a person in a care facility must be written by a prescriber on a separate prescription.

Charts that are not handwritten by the prescriber must comply with the standard rules for computer generated prescriptions or electronic prescriptions, as appropriate.

To be a legal order to supply or administer to a patient, a prescription on a medication chart must include:

• date prescribed
• name and address of the patient
• name and contact details of the prescriber
• details of the medicine - name, form, route, dose, instructions for use
• quantity to supply, treatment duration detail, or duration of validity of the chart
• signature of the prescriber.

Emergency Orders

In the event that a prescriber directs an authorised health professional to verbally in an emergency to administer a medicine to a person in residential care facility, then the prescriber must document the details of the order on the chart as usual, within 24 hours of giving the direction.

Emergency Direction to Pharmacists

In the event that a prescriber directs a pharmacy to supply aS4 or S8 in an emergency for a patient in hospital or residential care, orally, by telephone or other electronic means the prescriber must:

• prepare a document for that supply
• endorse the document with confirmation that directions were given
• send the document within 24 hours to the pharmacist.

If the pharmacist who supplied the S8 medicine does not receive the document within 5 working days of the supply, they must notify the CEO.

Orders on Charts should be legible and the directions clearly documented.

Any amendment to treatment, or cessation of treatment, should be clearly documented, signed and dated by the prescriber. Prescribing terminology should be consistent and standard terms and acceptable abbreviations should be used in accordance with the policy Standardisation of terminology, abbreviations and symbols in the prescribing and administration of medicines.

Charts are to be kept for a period of at least 2 years for S4 medicines or at least 5 years for S8 medicines.