CONCOMITANT MEDICATION LOG TEMPLATE | Smartsheet, Summaries of Nursing

CONCOMITANT MEDICATION LOG TEMPLATE. STUDY NO. STUDY TITLE. PRINCIPAL RESEARCHER. SUBJECT ID. SUBJECT INITIALS. Ask Participant: Are you currently taking ...

Typology: Summaries

2022/2023

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CONCOMITANT MEDICATION LOG TEMPLATE
STUDY NO. STUDY TITLE PRINCIPA L RESEARCHER SUBJECT ID SUBJECT INITIALS
Ask Participant: Are you currently taking any medications (i.e. prescription, vitamins, supplements, OTC drugs)?
NO. MEDICAT ION / THERAPY INDICATION DOSE DOSE UN ITS FREQ FORM RO UTE O F ADMI NIST RATIO N
START
DATE
dd/mm/yy
END
DATE
dd/mm/yy
BASE LINE
MED
Yes / No
CONTI NUING
AFTER STUDY
Yes / No
*To be signed at the end of the study
Date
Signature of Principal Researcher
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CONCOMITANT MEDICATION LOG TEMPLATE

STUDY NO. STUDY TITLE PRINCIPAL RESEARCHER SUBJECT ID SUBJECT INITIALS

Ask Participant: Are you currently taking any medications (i.e. prescription, vitamins, supplements, OTC drugs)?

NO. MEDICATION / THERAPY INDICATION DOSE DOSE UNITS FREQ FORM ROUTE OF ADMINISTRATION

START

DATE

dd/mm/yy

END

DATE

dd/mm/yy

BASELINE

MED

Yes / No

CONTINUING

AFTER STUDY

Yes / No Signature of Principal Researcher Date *To be signed at the end of the study

CODING CODE DOSE UNITS FORM

01 mg (milligram) Tablet

02 μg (microgram) Capsule

03 L (liter) Ointment

04 mL (milliliter)--- Suppository

05 IU (International Unit) Aerosol

06 g (gram) Spray

07 Suspension

08 Patch

09 Gas

10 Gel 11 Cream 12 Powder 13 Implant 14 Chewable 15 Liquid 99 Other, define Other, define Other, define QD (once/day)

FREQ

BID (twice/day) TID (three/day) QID (four/day) QOD (every other day) AC (before meals) PC (after meals) Other, define

ROUTE OF ADMINISTRATION

Oral Topical Subcutaneous Intradermal Transdermal Intraocular Intramuscular Inhalation Intravenous Intraperitoneal Nasal QM (every month) QOM (every other month) QH (every hour) Vaginal Rectal PRN (as needed)