Healthcare Conversion Chart

HEALTHCARE CONVERSION CHART

Purpose: This Healthcare Conversion Chart documents unit conversions and calculation results prepared for administration of medications and therapies for the identified patient. This chart is a clinical reference and recording tool only. The ordering and administering clinician is responsible for independent verification of all values, units, concentrations and patient-specific dosing before administration. Any alteration must be initialed and dated by the clinician.

Patient Information

Date of birth:    Gender:    Phone:

Insurance Information

Medical History (Relevant)

Conversion Reference Tables & Worksheet

Standard equivalencies (for clinician reference): 1 kg = 2.20462 lb; 1 tsp = 5 mL; 1 tbsp = 15 mL; 1 oz = 30 mL. Use institution rounding rules when applicable.

Weight Conversion

Weight (kg):    Converted weight (lb):

Medication Dose Calculation (Adult/Pediatric)

Desired dose:    Patient weight used:

Concentration available:    Calculated volume to administer (mL):

IV Infusion Rate

Total volume to infuse (mL):    Total time (hours):

Calculated rate (mL/hr):    Drop factor (gtt/mL):    Calculated drops/min (gtt/min):

Pediatric Weight-Based Dosing (if applicable)

Weight used (kg):    Dose (mg/kg):

Calculated total dose (mg):    Concentration (mg/mL):    Volume to administer (mL):

Temperature & Volume Conversions

Temperature: C to F — Celsius: → Fahrenheit result:

Volume quick reference recorded by clinician:

Clinical Verification & Notice

Warning: Verify patient identity, allergies, medication concentration and route prior to administration. All calculations must be independently checked by a second qualified clinician when required by institutional policy.

Chart valid through (enter expiration date for this worksheet):

HIPAA / Privacy Acknowledgment

I acknowledge that information recorded on this chart will become part of the patient's medical record and will be handled in accordance with applicable privacy laws and institutional policies. I consent to the use of these documented values in the patient’s clinical care.

I acknowledge and consent

Certification: By signing below I certify that I have reviewed the conversion calculations recorded above and that I understand the clinical use of this information. I acknowledge the responsibility to verify all items prior to administration.

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