Medication Log Template printable pdf download

Medication Log Template

MEDICATION LOG

55 Pa. Code §3270.133; §3280.133; §3290.133

PLEASE PRINT

Page _____ of _____

Child’s Name: _______________________________________

Medication: _____________________________________

⎕

Refrigeration Required: ⎕ YES ⎕ NO Expiration Date: _________________

Prescription

Non-Prescription

If Prescription, Prescriber’s Name: ___________________________________ Telephone: ___________________________

Dosage Amount: ________________

Time to Administer: ________ a.m.

________ p.m.

________ times/day

Dates for Administration:

From ____________________ To ____________________

Date

Special instructions i.e., symptoms signaling need for administration, medication indications, reasons to hold medication,

contradictions: _________________________________________________________________________________________

______________________________________________________________________________________________________

I give permission to administer medication to my child as stated above.

_______________________________________________________________

____________________________

Parent Signature

Date

FACILTY STAFF COMPLETE THIS SECTION

Date

Time

Amount of

Administered

Medication

Comments

Staff Initials

(mm/dd/yyyy)

(a.m. / p.m.)

Administered

Medication Log Template