Medication Documentation

 

  • The Authorization for Medication/Treatment Form must be checked carefully for the name of the student, name of the medication, dosage to be given, time to be administered, route to be administered, healthcare provider and parent signatures and expiration date. This should be done before you begin administering the medication.
  • The school must maintain a Student Medication Log for each student receiving medications. The log must state the name of the medication and the amount and time to be administered. A new log should be started at the beginning of each month. Each day of the month, with the exception of Saturdays and Sundays, are to be filled in at the beginning of each month. If a student is absent, or for any other reason does not receive the medication, this needs to be documented on the front of the Student Medication Log for that day with the appropriate code from the legend on the top of the log. A written explanation with the date and signature must be noted on the back of the Student Medication Log under Notes.
  • The authorized person administering the medication must initial the Student Medication Log after each dose. The Student Medication Log must be signed and dated weekly by each person administering medication.
  • The Student Medication Log and the Authorization for Medication/Treatment Form are to be kept together in a binder or folder. This medication binder must be at the location where medication is being administered.
  • The Student Medication Log must be placed in the student’s cumulative health folder after medication has been completed or at the end of each year.
  • The school is responsible for ensuring that the Documentation of Receipt of Medications is completed on the back lower portion of the Student Medication Log when a parent/guardian brings medication to the school. A school representative is to document the name, dosage, and amount of medication received. The parent/guardian is to sign when medications are delivered or picked up from the school.
  • If a medication dose is omitted for any reason, notify the parent as soon as possible. Document on the Student Medication Log why the medication was not administered. A narrative note must be written on the back of the Student Medication Log. Send a note home with the student to remind the parent that a dose was missed and what action was taken.
  • Parental requests to hold medications must be submitted in writing with specific dates and times. A copy of the parental request should be kept with the Authorization for Medication/Treatment Authorization Form and the Student Medication Log in the Medication Administration Binder. Document on the back of the Student Medication Log, in the narrative notes, that the medication was placed on hold along with the name of the parent who requested it.
  • Since the Student Medication Log is a legal document, correction fluid, erasures, correction tape or similar items are not to be used. Errors shall be crossed out with a single line and initialed. Then the information can be correctly entered.
  • In the event an entry onto the log is missed, the authorized person who omitted the notation is to document “Late Entry” and the current date the notation was made on the back of the log under Notes. For example, if it were realized on October 2nd that a medication that was given on October 1st was not documented, the authorized person would place their initials on the front of the log under October 1st and circle them. On the back of the log, under notes, the individual would write the date October 2nd Late entry: “Medication was administered on October 1 as ordered” and sign name.
  • When a medication is discontinued a red line should be drawn through the name of the medication on the Authorization for Medication/Treatment Form and the Student Medication Log. The date and the initials of the person discontinuing the medication should be placed next to the name of the medication. A notation is to be made on the back of the log as to the date and the name of the parent/guardian who requested that the medication be discontinued. If there are no other medications to be given the forms should be placed in the student’s Cumulative Health Folder.