Medication Administration Record Template (Page 2 of 2) in pdf

Controlled Substances: In accordance with federal and state laws, all doses of controlled medications (such as but not limited to ritalin,

adderall, dexedrine, valium and phenobarbital) must be accounted for on the student’s controlled substance medication

administration record.

Receiving Controlled Substance Medication: Controlled substance medications need to be received from a responsible adult (parent or

guardian) to the health service designee. If this is not able to be carried out, consult with Licensed School Nurse to assist with plan

for safe delivery of medication as follows:

Doses arriving at school must be counted and the number or amount recorded on student’s controlled substance record by completing the

following (below):

1. Count* the amount received.

2. After counting, record the amount received with the prescriptive number.

3. Count* and record the amount available prior to receiving more and the previous prescriptive number.

4. Add the two amounts as the total and date.

5. Transcribe this amount to the medication administration record (front page) in the upper portion of correct date followed by a back

slash.

* Medications that are not able to be counted (i.e. liquid or packaged gel preparations) will be estimated by health service designee.

* Health service designee to perform count and record with another person to verify.

Method to record administration of medication: Controlled substance administration record must include the following: name of student,

allergy, name, dose, time and route, special concerns/side effects and possible drug interactions, prescription number, amount

received, date received, amount dispensed and amount remaining, full signature of person receiving and/or counting and/or

administering medications.

1. All doses given must be recorded on controlled substance medication administration record by using “count back method”. In the

upper portion of box with the slash, write the amount on hand in the appropriate day/month. In the lower portion of same box, write

how much is remaining after dose given by subtracting from amount on hand. Initial each day. The following day you would review

count and in the upper portion, the amount from the previous day should be available and recorded, unless there has been more

medication received. If more medication received, complete (following steps above) and record on controlled substance record (below)

and add to the total amount on hand (upper portion of box). For example, if student Joan. the amount given and recording on the

correct date/time.

2. If medication is not given routinely (i.e. daily while at school), count medications at least monthly.

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(School Nurse may require more frequent count).

3. Any medication left at school after the medication is discontinued, at the end of the school year or

following the transfer of student to another program must be picked by the parent/guardian at school or

destroyed. If it is not possible for the parent/guardian to pick up medication, at the discretion of school

personnel, medication can be sent home with the student after notifying parent/guardian by phone of the

number of tablets being sent home with the student.

4. Any doses that are wasted or destroyed must be recorded on controlled substance record with

explanation of why and how destroyed. Controlled substances disposed of at school must be witnessed and signed by two health

designees. Before discarding the prescription bottle for a controlled substance, remove or blacken the label so it cannot be picked out

of the trash and refilled.

Controlled Substance Record

Recvd or

Date

RX #

Amount

Date

RX #

Already

Total

Signature/s

Sent

Avble

Notes:

Controlled Substance/Medication Administration Record 2006/jsa ISD 917 Special Education Programs

Medication Administration Record Template Page 2

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