Medication/procedure Log
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1Medication/Procedure Log
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Student Name: __________________________________________ DOB: _____________ Grade: ____________
Procedure or Medication Name: _______________________________________ Dosage: __________________ Time: ______
Route of medication: By mouth Inhaled
Injected Other ____________
NOTE: School Nurse to be notified of new or changed orders
M
T
W T
F
M
T
W T
F
M
T
W T
F
M
T
W T
F
M
T
W T
F
September
Initials
Time
Dosage
October
Initials
Time
Dosage
November
Initials
Time
Dosage
December
Initials
Time
Dosage
January
Initials
Time
Dosage
February
Initials
Time
Dosage
March
Initials
Time
Dosage
April
Initials
Time
Dosage
May
Initials
Time
Dosage
June
Initials
Time
Dosage
CODES (Enter a code for every day)
Initials and signatures of persons administering medication
Codes below require MED
or procedure:
Initials=medication/procedure
INCIDENT report
♦
administered as ordered
R=refused
♦
A=absent
N=student called, did not come
♦
♦
O=no medication supplied - document
NC=student was not called
♦
♦
calls to parents to request more meds
H=dose held for reason noted
♦
ns=no school
♦
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Parent category: Medical