Medication Log
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1
2Warren County Schools
School Health Services
Medication Log
Student
Parent
Legal Guardian
Date of Birth
School
School Year
Bus
Car
Cell Phone
Work Phone
Teachers
Home Phone
Grade
Lunch
Y
PE
Y
RETURN TO SCHOOL NURSE AT THE END OF SCHOOL YEAR
Medication
July
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Dose Amount
1
No. of Tablets per Dose
2
Time to Give
3
Name of Staff
Giving Medication
4
Write in your name + title + initials
5
6
7
Initial each day when
8
medication is given
9
10
Safety Checklist
11
Medication Form attached + signed
Medication Form Original to Nurse
12
Medicine Container Properly
13
labeled from pharmacy or store
14
Directions match on form + label
15
Medication in locked, secure area
Medication counted –recorded – signed
16
for each refill
~~~~~~
~~~~~~~~~
17
Signature of Person completing safety check
18
Procedure
19
1.
20
Complete Safety Checklist
2. Count # tablets each new bottle/refill
21
3. Document tablet count (see count box)
22
4. Each tablet count must be witnessed
23
5. Document each conversation with
parent/legal guardian about medication
24
6. Document Reason for missed doses
25
7. Other Comments – back of this log
26
Codes for Missed Medication
27
H
holiday
A
absent
28
C
change in dose
29
ER
early release
30
F
field trip
Vac
vacation day
31
(document on back)
W
withheld dose
*
Remember: count/document medication received (each time) with parent/legal guardian signature.
WD
workday
RETURN TO SCHOOL NURSE AT END OF THE SCHOOL YEAR
M
missed
*Document all parent/legal guardian contacts about medication. At the end of the year, send medication
AL
alternate location(ISS, ALS, ATS)
home with a parent/legal guardian co-signature. Never send medication home with student. At EOY, if
med not picked up after two documented efforts to contact parent/legal guardian, the medication should be
disposed/ wasted and signed by the school nurse and a witness (principal or designee).
School Nurse Signature
Date
File original in Individual Health Record
Revised: February 2016
SS-158
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Parent category: Medical