Medication Administration Record printable pdf download

Medication Administration Record

The Commonwealth of Massachusetts

Department of Early Education and Care

MEDICATION ADMINISTRATION RECORD

(This record must be maintained in the children’s file when completed)

606 CMR 7.11 (1-3)

FOR STAFF USE:

Who trained the staff? _________________________________

Has the Medication Consent form been completed? ____

Have the “5 rights” been addressed? ____

Is the medication in a safety cap container? ___

Is the original prescription label on the medication container? ___

Is the name of the child given below on the container? ___

Is the date on the prescription current (within the month for antibiotics and within the

expiration date for medications which are so labeled; within the year otherwise? ___

Is the dose, name of drugs, frequency of administration given on the label consistent with

parental instructions?___

Medication can be administered only if the answers to all questions above are “Yes”

CHILD’S NAME____________________________________MEDICATION_______________________

DATE

TIME

MEDICATION

DOSE

ROUTE

STAFF

MISDOSES

CHILD

SIGNATURE

ERRORS

REFUSAL

Did you check the label 3 times?________

If child refused medication explain why?____________________________________________

SG/LG/SAMedicationAdministration20100122

Medication Administration Record