Child Care Medication Authorization Form Page 2

Child’s Name:___________________________ Name of Medication:________________________ Child’s Primary Group:_________________________

ALWAYS review the written Parent/Guardian medication instructions and Health Care Provider's medical order (when necessary according to regulation)

prior to EVERY administration. Instructions should be attached to this sheet.

7 Rights MUST be performed with EVERY dose!

Right child, Right medication, Right dose, Right route, Right time, Right reason, Right documentation

Time last

CONTROLLED SUBSTANCES

Date

Time

Dose

Route

Quality

dose was

Comments/Reactions

Given

given by

# on

Check

# Given

Staff Signature

Guardian

Hand

Remain

When medication has been discontinued, it should be returned to the parents or disposed of properly.

0 votes

Parent category: Legal