Medication Administration Record Template
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1
2Student Name:
Time:
_______ Routine or PRN (circle)
Allergies:
Physician:
School Yr:
Medication:
Dose:
Frequency
Route:
Directions/Special Concerns/Side effects (Controlled: see backside)
If PRN, as needed for:
:
Medications administered have been reviewed for possible side effects and interactions by
Initial Date Medication Started at School:
Date Stopped:
Changes:
Date:
Dose:
Time:
Changes:
Date:
Dose:
Time:
Changes:
Date:
Dose:
Time:
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
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
30
31
Abbreviations: A= Absent
X= No School
H= Bottle Home
NMA= No Med Available
R=Refused
Initialed &Circled = Did Not Take
Initial
Signature
Initial
Signature
Controlled Substance/Medication Administration Record 2006/jsa ISD 917 Special Education Programs
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Parent category: Medical