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Medication Administration Record

MEDICATION ADMINISTRATION RECORD

(must be kept with the child’s written medication authorization form)

Has the Medication Authorization form been completed by the parent?

Is the medication in a child-proof container?

Is the original prescription on the medication container?

Is the child’s name on the container?

Is the date on the prescription current?

Are the dose, name of drug, frequency of administration given on the label consistent with parental instructions?

Child’s Name _________________________ Birthdate _____________ Class ______________

Name of Medication: _________________________________ Effective Dates of Authorization ____________ to ______________

Date

Time

Route

Dose

Symptoms exhibited

Parents Notified of

Any noted side

Administered By (name,

M/D/Y

am/pm

by child

Administration Y/N

effects/parents

signature)

notified Y/N

This section for medication errors (not given as indicated on authorization form). Indicate date/time of error, details of/reason for error, parental

notification, and staff signature. Use reverse side if needed.

___________________________________________________________________________________________________________________

Medication Administration Record