ATTACHMENT E - DOCTORS ORDERS.doc
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- R408--PHARMACY BENEFIT MANAGEMENT: VISN 22
- Solicitation number
- 36C26221R0017
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| 36C26221R0017 0002.docx | DOCX document | |
| 36C26221R0017 0001.docx | DOCX document | |
| ATTACHMENT C - BUSINESS ASSOCIATE AGREEMENT.docx | DOCX document | |
| ATTACHMENT A - PRICE WORKSHEET.xlsx | XLSX spreadsheet | |
| ATTACHMENT B - PARTICIPATING FACILITIES.docx | DOCX document | |
| 36C26221R0017.docx | DOCX document | |
| ATTACHMENT G - WD LA 2015-5613 REV. 16.pdf | ||
| ATTACHMENT F - PRESCRIPTION FORM.doc | DOC document | |
| ATTACHMENT D - IT CONTRACT SECURITY.pdf | ||
| ATTACHMENT I - WD SD 2015-5635 REV. 14.pdf | ||
| ATTACHMENT H - WD SB 2015-5629 REV. 14.pdf |
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Text version
Department of Veteran Affairs
MEDICAL RECORD – DOCTOR’S ORDERS
NOTE – Physician’s signature must accompany each entry and including standing orders. Date and time for instituting and discontinuing the orders must be recorded.
DATE AND TIME
(1)
PROB. NO
(2)
ORDERS
(ANOTHER BRAND EQUAL IN QUANTITY AND OF SAME BASIC DRUG
MAY BE DISPENSED UNLESS CHECKED)
(3)
(4)
NURSE’S
SIGNATURE
(5)
PATIENT INORMATION (NAME, ADDRESS, SOCIAL SECURITY NUMBER)
MEDICAL RECORD
DOCTOR’S ORDERS
| VA FORM |
| 10-1158 |
FEB 1992
ORDER THROUGH NORMAL SUPPLY CHANNELS
USE BALL POINT PEN NO CARBON PAPER REQUIRED PLEASE PRINT
PROB. NO.
DOCTOR’S ORDERS – MEDICATION RECORD
| DATE |
| TIME ORDERED |
| NURSE’S INITIALS |
R.N.
Another brand, equal in quality, of the same
Basic drug may be dispensed UNLESS checked.
-------------- > FORMCHECKBOX
SIGNATURE AND TITLE OF PHYSICIAN OR DENTIST
◄ IMPRINT FROM PATIENT DATA CARD
PROB. NO.
DOCTOR’S ORDERS – MEDICATION RECORD
| DATE |
| TIME ORDERED |
| NURSE’S INITIALS |
Another brand, equal in quality, of the same
-------------- > FORMCHECKBOX
SIGNATURE AND TITLE OF PHYSICIAN OR DENTIST
◄ IMPRINT FROM PATIENT DATA CARD
PROB. NO.
DOCTOR’S ORDERS – MEDICATION RECORD
| DATE |
| TIME ORDERED |
| NURSE’S INITIALS |
Another brand, equal in quality, of the same
-------------- > FORMCHECKBOX
SIGNATURE AND TITLE OF PHYSICIAN OR DENTIST
◄ IMPRINT FROM PATIENT DATA CARD
Action Rx Profile for extra prescriptions Site:
____________________________________________________________SB VA OPC
Name:___________________________________________ Date: ________________________
SS# ___________________________________________
Address: ______________________________________________________________________
Phone: ______________________________________ Weight (kg) _________ Height ________
Instructions to the provider:
A prescription blank (VA FORM 10-2577f) must be used for all Class II NARCOTICS_________
1. Medication ________________________________________________________________
Outpatient Directions ________________________________________________________
__SC___NSC Quantity:_______ Days supply: __________ Refills 0 1 2 3 4 5 6 7 8 9 10
Provider’s Signature DEA# Date AND Time
2. Medication ________________________________________________________________
Outpatient Directions ________________________________________________________
__SC___NSC Quantity:_______ Days supply: __________ Refills 0 1 2 3 4 5 6 7 8 9 10
Provider’s Signature DEA# Date AND Time
3. Medication ________________________________________________________________
Outpatient Directions ________________________________________________________
__SC___NSC Quantity:_______ Days supply: __________ Refills 0 1 2 3 4 5 6 7 8 9 10
Provider’s Signature DEA# Date AND Time
4. Medication ________________________________________________________________
Outpatient Directions ________________________________________________________
__SC___NSC Quantity:_______ Days supply: __________ Refills 0 1 2 3 4 5 6 7 8 9 10
Provider’s Signature DEA# Date AND Time
5. Medication ________________________________________________________________
Outpatient Directions ________________________________________________________
__SC___NSC Quantity:_______ Days supply: __________ Refills 0 1 2 3 4 5 6 7 8 9 10
Provider’s Signature DEA# Date AND Time
Attachment B
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