Medication Administration Record

MEDICATION ADMINISTRATION RECORD
INITIAL EACH ENTRY. RECORD TIME MEDICATION IS GIVEN OR USE CODE IF NOT GIVEN.

Student Name
/ Grade / DOB
/ School
BurrDwightEarly Childhood CenterHolland HillJenningsMcKinleyMill HillNorth StratfieldOsborn HillRiverfieldShermanStratfieldFairfield WoodsRoger Ludlowe MiddleTomlinsonFairfield Warde HSFairfield Ludlowe HSFairfield Public Schools
/ Personnel trained to give this medication / Physician/Prescriber / Allergies
Order Date
/ Order End Date
D/C Date if earlier:
/ Medication
ACETAMINOPHENADDERALLADVAIRADVILALBUTEROLALEVEBENADRYLDIASTATDIPHENHYDRAMINEEPI-PENEPI-PEN JUNIORFLOVENTIBUPROFENLACTAIDMAXAIRMETHYLPHENIDATEMOTRINNAPROXENPROVENTILRITALINSINGULAIRTYLENOLVENTOLIN
/ Dose
Route POINHALEDTOPICALSCIMSC or IMR EARL EARBOTH EARSL EYE R EYEBOTH EYESINTRANASALPRSUBLINGUALG-TUBEBUCCALTRANSDERMALIV
Frequency Before lunchBefore snackBefore lunch/snackLunchtimeSnacktimeQ.I.D.T.I.D.B.I.D.QDQ6HRQ4HRQ3HRQ2HRQ1HRQHSBefore gymBefore recessBefore gym/recessContinuous prn
/ Condition Being Treated
Time to be given (7 a.m. to 6 p.m.) / Special Instructions
Monday
/ Tuesday
/ Wednesday
/ Thursday
/ Friday

DAY/HOUR (7 AM TO 6 PM) INITIALS. DOCUMENT DOSE IF A RANGE OF DOSES IS ORDERED.

MO/
YEAR /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 /
11 /
12 /
13 /
14 /
15 /
16 /
17 /
18 /
19 /
20 /
21 /
22 /
23 /
24 /
25 /
26 /
27 /
28 /
29 /
30 /
31
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028
Jan.Feb.Mar.AprilMayJuneJulyAug.Sept.Oct.Nov.Dec.
201420152016201720182019202020212022202320242025202620272028

A=ABSENT R=REFUSED N=NARRATIVE E.D. =NOT GIVEN-EARLY DISMISSAL

NURSE/STAFF SIGNATURE / INITIALS / NURSE/STAFF SIGNATURE / INITIALS / NURSE/STAFF SIGNATURE / INITIALS / NURSE/STAFF SIGNATURE / INITIALS