CODE-UD in psychiatric education.
Morra & Ban
DRUG HISTORY
PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER:
THIS FORM NEEDS TO BE COMPLETED PRIOR TO ANY CODE-UD PROCEEDURE
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME (sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME (sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME
(sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME (sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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---------- -------- --------- ---- ----- ---- ----------- ---
PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME (sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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---------- -------- --------- ---- ----- ---- ----------- ---
---------- -------- --------- ---- ----- ---- ----------- ---
PATIENT NUMBER:
RATER NUMBER:
DATE:DD-MM-YYYY
ASSESSMENT NUMBER
- MEDICATION
GENERIC NAME - TRADE NAME - FORMULATION - DOSE - ROUTE - DOSE REGIME (sup, tab, cap, sol, vial) (mg X d) (O, REC, SL, SC, IM, IV,) (QD, BID, TID, QID)
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