Medication Administration Log
Child’s Name: ____________________________ Date of Birth:____________________ Rm:__________________
Medication:_____________________________________________________________ Time:_________________
Amount:_____________ Route:_____________ Start Date for Medication:_________ End Date:______________
Special Instructions:_____________________________________________________________________________________
Name of Health Care Provider Prescribing Medication:_______________________________ Phone:________________
Parent Name: _________________________ Parent Work #:___________________ Parent Home #:_______________
Week of: Week of:
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Fri. Date |
Mon Date |
Tues. Date |
Wed. Date |
Thurs. Date |
Fri. Date |
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P.M. |
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Include Time Medication was Given and Initial If the child is absent, mark box with an “A” ; If the medication was not given, mark box “NG”. Document reason medication was not given in Comments.
Date & Comments:
Pills Received: (All controlled medications must be counted, e.g. Ritalin) Signatures Staff Initials
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