Medication Log Page 2
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2Medication Log: Parent/Guardian Documentation and Comments
# Rcv’d
Date
Name of Medication
Date
Date
Staff Signature
Co-Signature
Rx Filled
Rx Expires
(staff or parent/legal guardian)
E,O.Y. #1
Parent/Legal Guardian Contact to Pick up Medication
Date
Time
E,O.Y. #2
Parent/Legal Guardian Contact to Pick up Medication
Date
Time
End of Year: Medication picked up by
Amount of Med. released Witnessed by
Date
Time
End of Year: Medication disposed/wasted by
Date
Time
Witnessed by:
Date
Time
Amount Wasted
Method of Disposal
Flushed
Trashed with coffee grounds in plastic bag Take back program
Other Comments
Date
(document all parent/legal guardian contacts)
File original in Individual Health Record
Revised February 2016
SS-158
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Parent category: Medical