Sample Medication Administration Daily Log
ADVERTISEMENT
1
2Sample Medication Administration Daily Log
(To be completed for each medication)
School Year __________________________
Name of Student________________________________ Date of Birth ________________ Sex ___ Grade/Home Room (or Teacher)
_______________________________________________
Name of School _________________________________________________
Name and Dosage of Medication______________________________________ Route ________ Frequency __________ Time(s) Given in School _____________________
Directions: Initial with time of administration; a complete signature and initials of each person administrating medications should be included below.
30
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
31
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
INITIAL
SIGNATURE
CODES*
(of person administering medication)
1. ________ __________________________________
______________________________ (A) Absent
(O) No Show
2. ________
__________________________________
______________________________ (E) Early Dismissal (W) Dosage Withheld
3. ________
__________________________________
______________________________ (F) Field Trip
(X) No School (e.g.., holiday,
weekend, snow day, etc.)
4. _______
__________________________________
______________________________
(N) No Medication Available
Use reverse side for reporting significant information (e.g. observations of medication’s effectiveness, adverse reactions, reason for omission, plan to prevent future “no shows”).
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical