Medication Administration Packet
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1 Medication Administration Packet CHILD S INFORMATIONPRESCRIBER S INFORMATION Authorization to Give Medicine PAGE 1 TO BE COMPLETED BY PARENT/GUARDIAN / / Name of Facility/School Today s Date / / Name of Child (First and Last) Date of Birth Name of Medicine Reason medicine is needed during school hours Dose Route Time to give medicine Additional instructions Date to start medicine / / Stop date / / Known side effects of medicine Plan of management of side effects Child allergies PRESCRIBER S INFORMATION Prescribing Health Professional s Name Phone Number PERMISSION TO GIVE MEDICINE I hereby give permission for the facility/school to administer medicine as prescribed above. I also give permission for the caregiver/teacher to contact the prescribing health professional about the administration of this medicine. I have administered at least one dose of medicine to my child without adverse effects. Parent or Guardian Name (Print) Parent or Guardian Signature Address Home Phone Number Work Phone Number Cell Phone Number
2 AA Receiving Medication PAGE 2 TO BE COMPLETED BY CAREGIVER/TEACHER Name of child Name of medicine Date medicine was received / / Safety Check 1. Child-resistant container. 2. Original prescription or manufacturer s label with the name and strength of the medicine. 3. Name of child on container is correct (first and last names). 4. Current date on prescription/expiration label covers period when medicine is to be given. 5. Name and phone number of licensed health care professional who ordered medicine is on container or on file. 6. Copy of Child Health Record is on file. 7. Instructions are clear for dose, route, and time to give medicine. 8. Instructions are clear for storage (eg, temperature) and medicine has been safely stored. 9. Child has had a previous trial dose. Y N 10. Is this a controlled substance? If yes, special storage and log may be needed. Caregiver/Teacher Name (Print) Caregiver/Teacher Signature
3 Medication Log PAGE 3 TO BE COMPLETED BY CAREGIVER/TEACHER Name of child Weight of child Medicine Monday Tuesday Wednesday Thursday Friday Date / / / / / / / / / / Actual time given Dosage/amount Route Staff signature Monday Tuesday Wednesday Thursday Friday Medicine Date / / / / / / / / / / Actual time given Dosage/amount Route Staff signature Describe error/problem in detail in a Medical Incident Form. Observations can be noted here. Date/time Error/problem/reaction to medication Action taken Name of parent/guardian notified and time/date Caregiver/teacher signature RETURNED to parent/guardian DISPOSED of medicine Date Parent/guardian signature Caregiver/teacher signature / / Date Caregiver/teacher signature Witness signature / /
4 AA Medication Incident Report Date of report School/center Name of person completing this report Signature of person completing this report Child s name Date of birth Classroom/grade Date incident occurred Time noted Person administering medication Prescribing health care provider Name of medication Dose Scheduled time Describe the incident and how it occurred (wrong child, medication, dose, time, or route?) Action taken/intervention Parent/guardian notified? Yes No Date Time Name of the parent/guardian that was notified Follow-up and outcome Administrator s signature Adapted with permission from Healthy Child Care Colorado.
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