Michigan Department of Education
Michigan Department of Community Health
Administration of Medication
in Schools
MODEL SCHOOL NURSE GUIDELINE
Original Date of Issue: 2014
Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
Introduction
Many students need medications during school hours. The administration of medication in the school
setting is a service that is provided to promote wellness and decrease absenteeism and to remove a
barrier to learning. When there is a need for a student to receive medication in school, safe and proper
administration is essential. Schools are required to have a medication policy in accordance with Section
380.1178 of the Michigan School Code.
1
This policy reflects guidelines set forth in a Michigan
Department of Education memorandum dated November 20, 2002.
2
This medication policy and the medication authorization/parental consent form should be communicated
to parents and to local physicians, dentists, and health care providers at least annually in the school’s
handbook, by posting on the school’s website or notifying parents and physicians where a copy can be
obtained.
Definitions:
Medication Administration: The Michigan Department of Education, in interpreting Section 380.1178 of
the School Code, defines medication administration "as maintaining and providing medication to
students in the school setting.”
Medication: includes both prescription and non-prescription medications taken by mouth, taken by
inhaler, are injectable (i.e. auto-inject epinephrine, insulin, and glucagon), rectal installation, applied as
drops to eye or nose, or applied to the skin.
I. PRESCRIPTION MEDICATION
A. Authorization to Administer Medication
All prescription medication to be given in school must be ordered by a licensed healthcare
provider authorized to prescribe medication. In Michigan, an authorized prescriber is a
licensed dentist, a licensed doctor of medicine, a licensed doctor of osteopathic medicine and
surgery, a licensed doctor of podiatric medicine and surgery, or a licensed optometrist. Nurse
practitioners and physician assistants can prescribe under delegation of MD or DO. An
approved medication administration/authorization form (see Appendix) should be used and
should contain the following information:
Date of order
Name of student
Diagnosis
Name of medication to be administered
Dosage
Time of administration
Route of administration
Duration of medication order
Possible side effects
Special requirements such as “take with food”
Whether or not medication may be self-administered
1
Section 380.1178 of the Michigan School Code, The Revised School Code (Excerpt) Act 451 of 1976
2
This guideline is based on MDE’s Model Policy and Guidelines for Administration of Medication(2002)
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
The approved medication administration/authorization form must be signed by the authorized
prescriber and the parent/guardian. A printed name stamp is not acceptable. A written
parent/guardian authorization must accompany each medication order. An order must be
renewed annually (or more often as necessary) even if the order is for an “as needed”
medication. The authorization should be filed in the student's school health record.
Faxed medication orders for the administration of medication may be accepted when submitted
on a written, approved authorization form and signed by an authorized prescriber. The parent
should sign the form within five (5) days.
B. Parental Consent
Written parental consent and request to administer medication is required for each
medication ordered and for each new order (even if the medication was previously given in
school). Parental consent is required as a part of the authorization (see Appendix for
Medication Administration/Authorization Form) and is required before medications will be
administered.
Parental consent forms should be filed in the student's school health record. Parental or
guardian request/permission should be renewed annually, or more often, if necessary.
Prescription and medication supply renewal should be the responsibility of the
parent/guardian.
C. Labeling, Storage, and Disposal
The medication container shall accompany all medications to be administered in school.
Parents/guardians may request two containers (one for school and one for home) from the
pharmacist when getting a prescription filled. Medications should be brought to the school by
the parent or responsible adult, especially for elementary school students. However, if this is
not possible, the parent/guardian should inform the school nurse, principal, or designee by
telephone that his/her child is bringing the medication to school and how much medication is
in the container. This eliminates any question about how much medication should have been
in the container when the child reached the school. The amount of medication received, if a
controlled medication, should be checked by the school nurse, school administrator, or
designee and witnessed by a responsible employee, and documented as soon as the
parent/guardian delivers the medication.
The medication should be kept in a labeled container as prepared by a pharmacy, physician, or
pharmaceutical company and labeled with:
Name of student
Name of medication
Dosage of medication to be given
Frequency of administration
Route of administration
Name of physician ordering medication
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
Date of prescription
Expiration date
See note regarding over-the-counter (OTC) medication below.
Expiration dates should be checked periodically, especially on auto-inject epinephrine and
inhalers.
The medication should be provided to the school in the exact dosage ordered.
In compliance with the safe standards, all medication must be stored in a securely locked,
substantially constructed cabinet, room, or cart
3
(see exception below for self-administration).
Medications that must be refrigerated must be stored in a locked box in the refrigerator.
Access to medication locked in the designated space shall be under the authority of the school
nurse, the principal, and/or designee.
All medication must be removed from the school premises one week after the expiration date,
upon appropriate notification of medication being discontinued, or at the end of the school
year. If not retrieved by a parent or responsible adult, unused and unclaimed medication will
be disposed of following the school district’s local policy that may include community drop off
locations. Empty asthma inhalers may be disposed of in the trash. Sharps (needles and
lancets) must be disposed of in a puncture proof container. Disposal of this container and
other medical waste must follow Occupational Safety Health Act (OSHA)/Michigan
Occupational Safety and Health Administration (MIOSHA) guidelines.
D. Administration of Medication
The school nurse, in collaboration with the school administrator, implements the medication
policy. School staff and parents shall be informed annually of the medication policies and
procedures.
The parent/guardian should give the first dose of any new prescription or over-
the-counter medication, except for “as needed” emergency medications (e.g.
auto-inject epinephrine).
Medication must be administered by one adult in the presence of a second
adult (except in an emergency that threatens the life of the student), with both
individuals being designated by the school administrator and approved by the
school nurse.
A record (medication administration record or MAR), by individual, must be
maintained each time a medication is administered.
The record (MAR) shall include: student's name, name of medication, date and
time of administration, dosage, and signature of person administering the
medication. The witness (second adult in attendance) should initial the MAR. If
an error is made in recording, the person who administered should line out,
initial the error, and make the correction in the MAR. (See Appendix for MAR.)
3
Michigan Administrative Rules, Section R 338.3143 Storage of controlled substances.
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
The individual student medication record should be kept until one year after the
student's graduation from high school.
E. Self-Administration of Medication
It must be determined by the school nurse whether a student who self-
ad
ministers medication is responsible to self-carry their medication. The
developmental ability of the student, the need to have ready access to
emergency medication and the safe storage of medication must be taken into
account when making this decision.
A plan should be developed for students who self-administer. A physician must
au
thorize self-administration of medication. (See Appendix Medication
Authorization/Parental Consent Form). The plan shall address how to keep a
record of administrations.
The student's parent/guardian must provide written permission and request to
the s
chool to allow student to self-possess and self-administer medication.
The parental or guardian request/permission and physician's instructions should
be renewed annually, or more often, if necessary.
All medication should be kept in a labeled container as prepared by a pharmacy
or pharmaceutical company and labeled with dosage and frequency of
administration. This language also pertains to refills.
Together, the school nurse/building administrator may discontinue the student
self-
administration privilege upon advance notification to the parent/guardian.
If a student is under an Individualized Educational Program (IEP) or Section 504
Plan, the action must be taken in accordance with Individuals with Disabilities
Education Act (IDEA) or Section 504 or the Rehabilitation Act requirements.
A student who requires the use of an inhaler for relief or prevention of asthma
sy
mptoms will be allowed to carry and use the inhaler if there is written
approval from the student’s physician and parent/guardian;
A student who is in possession of an inhaler or other medications approved for
self c
arry under the above conditions shall have each teacher notified of this by
the building administrator/or designee.
II. NARCOTICS AND OTHER CONTROLLED MEDICATIONS
If a narcotic or other controlled medication must be administered in school, the guidelines for
prescription medications should be followed with the following modifications:
The parent/guardian shall bring the medication to school
Medication Administration 5 2014
Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
The amount of the drug received shall be immediately counted and recorded by
the school nurse or designee, and witnessed by a responsible employee
Narcotics or other controlled medications shall be counted on a scheduled basis
(monthly, bi-weekly) by the school nurse and witnessed by a responsible
employee. This count should be reconciled with the prior count and medication
administration record
The school nurse should maintain no more than a 30-
day supply of narcotics
There must be a new order and parent authorization every 30 days EXCEPT if
the narcotic is to be given “as needed.” If the narcotic is to be given “as needed”
and for more than thirty days, the school nurse should contact the parent or
prescriber to confirm the continued need for the medication, especially in cases
where the medication is classified as a narcotic.
LLL. OVER-THE-COUNTER (OTC) MEDICATIONS
Administration of OTC medication must be conducted in accordance with the guidelines for
prescription medication. The only exception is if the school has adopted “physician directed
nursing protocols” for the administration of OTC medication; If the school district has adopted
“physician directed nursing protocols,” the following should be incorporated in the policy:
The school and school nurse shall identify which OTC medications are to be
ad
ministered under its policy.
Parental consent is required annually for the administration of the identified
OTC medications.
Administration of the identified OTC medications must be part of a nursing
protocol which has been approved by the school, the school nurse program
manager, and the medical director.
Only registered nurses may make the assessment and the decision to administer
an
OTC medication; therefore the school’s “physician directed nursing
protocols” may only be used in schools when a licensed nurse is present.
Medications administered under the scho
ol’s “physician directed nursing
protocols” are not to be given for a problem/health concern diagnosed by the
child’s primary care physician. The guidelines for prescribed medication must be
followed when this occurs.
In the absence of an order from an authorized prescriber for a medication that
is in
cluded in the “physician directed nursing protocols” the school’s “physician
directed nursing protocols” may be followed if parental permission is obtained;
! student’s specific medication order from an au
thorized prescriber shall take
precedence over the school’s “physician directed nursing protocols.”
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
OTC medication must be brought to school in an original container that should
be unopened; The OTC container will be labeled with the student’s name and
DOB by the school nurse or designee.
IV. DELEGATION OF MEDICATION ADMINISTRATION TO UNLICENSED STAFF
A. Delegation
In accordance with the Board of Nursing General Rules on Delegation
4
, only a registered
nurse may delegate nursing acts, functions, or tasks. As part of the delegation procedure,
the school nurse will determine which student care activities may be delegated, under
what circumstances it is appropriate to delegate, and by whom the delegated portions of
care can safely be provided.
5
The assignment of those functions is jointly decided upon
by the school administrator and the nurse.
B. Liability
Sec. 380.1178.
6
"A school administrator, teacher, or other school employee designated
by the school administrator, who in good faith administers medication to a pupil in the
presence of another adult or in an emergency that threatens the life or health of the
pupil, pursuant to written permission of the pupil's parents or guardian, and in
compliance with the instructions of a physician is not liable in a criminal action or for civil
damages, as a result of the administration except for an act or omission amounting to
gross negligence or willful and wanton misconduct."
C. Staff Selected to Administer Medication
Plans for the administration of medications in the absence of the nurse shall be
developed collaboratively by the school nurse and the school administrator. The decision
regarding delegation of medication administration should be considered in conjunction
with other school duties, such as lunch and recess supervision. Such comprehensive
planning will ensure that the most appropriate person is assigned to each task and that
medication administration is completed in a safe manner.
Criteria for Personnel Selected to Administer Medication in the Absence of the School
Nurse: In all cases, the person should:
Be an employee and agree to this responsibility
Have good attendance
Be familiar with the students in the school
Possess good organizational skills
Handle stress in a calm manner
Have coverage/assistance available for regularly assigned job duties during
peak times when medications must be given (usually between 11:00 a.m. and
1:00 p.m.)
Be in a quiet environment that allows for safe and effective administration of
4
Section R 338.10104 of the Board of Nursing General Rules on Delegation (Rule 104).
http://www.state.mi.us/orr/emi/admincode.asp?AdminCode=Single&Admin_Num=33810101&Dpt=&RngHigh=33923405
5
Delegation of School Health Services, NASSNC Position Paper. Draft 2009.
6
THE REVISED SCHOOL CODE (EXCERPT) Act 451 of 1976, Sec. 380.1178 Administration of medication to pupil; liability; school
employee as licensed registered professional nurse.
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
medications.
Medication must be administered by one adult in the presence of a second adult (except
in an emergency that threatens the life of the student), with both individuals being
designated by the school administrator and approved by the school nurse.
Since the majority of medication doses are scheduled for administration between the
hours of 11:00 a.m. and 1:00 p.m., plans must include considerations for these persons’
lunch.
Safe nursing practice requires that persons administering medications under the
direction of a nurse be appropriately trained and supervised.
7
School staff who
administer medication must complete the School Nurse Program’s approved Medication
Administration Course. This training provides instruction in the administration of oral
medications. Administration of medication by any other route requires that the nurse
train the unlicensed person. Records of the date and nature of the initial training and re-
certification must be maintained. At the conclusion of the training, the school
administrator and nurse should make a final decision as to the appropriateness of the
assignment for the individuals trained.
Schools must make plans for periodic direct supervision by licensed nurses of personnel
assigned responsibility for medication administration. Registered nurses (or a LPN if
designated to do so by a RN) should maintain records of this supervision. (See Appendix
for Skills Checklist.)
Each person assigned routine responsibility for medication administration should have at
least one person designated as an alternate to substitute in the case of absence.
Selection and training of alternates should follow the same criteria and Medication
Administration training process outlined above. School staff assigned responsibility for
medication administration should have regular opportunities to administer medications
in order to reinforce training and ensure that skills are maintained.
Medication administration is not an appropriate assignment for an unlicensed school
volunteer.
V. ADMINISTRATION OF MEDICATION ON SCHOOL-SPONSORED ACTIVITIES
Medications should be administered to students on school-sponsored trips only when absolutely
necessary. Timing of doses should be adjusted to occur outside of the school-sponsored activity
period if medically appropriate. Medications may be administered on school-sponsored trips only
when previously administered and a parent permission form is on file. The only exception is
emergency “as needed” medications. A written, approved authorization form is required for all
medications. The determination of whether a medication is administered during a school-
sponsored activity and by whom shall be determined by the school nurse in collaboration with
the school administrator and parents. Options for administration of medications during field trips
7
Defined by Michigan PUBLIC HEALTH CODE (EXCERPT), Act 368 of 1978, 333.16109 Definitions; S to T.
Medication Administration 8 2014
Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
may include the following:
Parent/guardian may accompany student on the field trip and administer the
medication.
A parent may request from the pharmacy that a single dose of medication for the
field trip be placed in a properly labeled prescription bottle or OTC container to be
given on the school-sponsored trip by school personnel.
The medication bottle that the school has can be sent on the field trip. Upon
completion of the field trip, the labeled container should be returned to the health
suite. A notation shall be made on the student's medication record that the
medication was administered. The person who administered the medication is
responsible for documenting the administration of that medication in accordance
with policy.
VI. ERRORS IN THE ADMINISTRATION OF MEDICATION
If an error in medication administration occurs (such as missing a dose, giving the incorrect dose,
giving a dose at the wrong time, giving incorrect medication to the student, or giving a student
another student's medication even if the medication was the same drug and dose), follow the
procedures listed below:
Contact the school nurse and building administrator, and School Nursing Program
M
anager, if appropriate, immediately.
Observe the student for untoward side effects.
Take appropriate action based on nursing judgment and/or physician order. If
necessary, 911 should be called.
The building administrator or designee should notify the parent and suggest
consultation with the physician/pharmacist/school nurse program manager and
primary care provider of the child.
Complete the appropriate reporting forms (see Incident report in the Appendix).
D
ocument the specifics of the incident and the action taken. A report of the error
should be made and filed per school district policy.
VII. STOLEN OR LOST MEDICATION
If any medication is reported missing, the school administrator and the School Nursing Program
Manager shall be notified and procedures for missing property on school grounds should be
followed. Since the incident may involve controlled, dangerous substances, notification of the
police may be appropriate. Parents shall also be told in order to replace the medication.
Appropriate documentation shall be completed and the school nurse shall keep a copy of the
documentation.
VIII. EDUCATION ON THE USE OF MEDICATION
Depending on the school nurse’s assignment, it is strongly recommended that the school nurse
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Michigan Department of Education, Michigan Department of Community Health GUIDELINES:
Administration of Medication in Schools
assess and provide health education for students regarding their prescribed medications. This
education should support/supplement the educational program implemented by the student’s
health care provider. Health education should include appropriate management of all aspects of
a student’s health maintenance including medication administration;
Since medication taken in school often assists the student to be available for instruction, the
school nurse may work with the parent and school team to address issues surrounding the use of
medication at school. This should include developing plans to assist students to remember to
come to the health room for their medication.
IX. HIPAA (HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT)
If the school nurse has concerns about the medical orders or wants to share information that
may be relevant to the treatment regimen with the physician, the school nurse and physician
may communicate with each other regarding the medical orders and treatment regimen without
written authorization of the parent. HIPAA allows health care professionals to share protected
health information if it is for treatment purposes. Furthermore, regardless of the healthcare
setting, state licensure statutes and professional standards of practice for nurses and physicians
require nurses to question and clarify medical orders, when indicated, before carrying them out.
They also require physicians to provide nurses with sufficient information for safe execution of
the treatment plan. Therefore, such communication is based on state law and necessary.
Adapted and used with permission from MEDICATION ADMINISTRATION IN SCHOOLS, MARYLAND STATE SCHOOL
HEALTH GUIDELINE, 2006. Maryland State Department of Education Student Services and Alternative Programs and
Maryland Department of Health Mental Hygiene Center for Branch Maternal & Child Health
Appendix
Authorization form
Count form
Incident report
MAR
Skills checklist
Release of records
Medication Administration 10 2014
School Nurse Program
Medication
Administration in
Schools
Medication Forms
Medication Administration 12 2014
Me
___________________________________________________
School Nurse Program
SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM
This order is valid only for school year (current) ___________________ including the summer session.
School: _______________________________________________________________________________
This form must be completed fully in order for schools to administer the required medication. A new medication administration form must
be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of
administration of a medication.
* Prescription medication must be in a container labeled by the pharmacist or prescriber.
* Non-prescription medication must be in the original container with the label intact.
* An adult must bring the medication to the school.
* The school nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the child and/or the child’s medication;
Prescriber’s !uthorization
Name of Student: _______________________________________________ Date of Birth:__________________ Grade: __________
Condition for which medication is being administered: ___________________________________________
Medication Name: ______________________________________Dose: ______________________Route: ___________________
Time/frequency of administration: ________________________________________________ If PRN, frequency: ________________
If PRN, for what symptoms: __________________________________________________________________________________
Relevant side effects:
□ None expected □ Specify: ______________________________________________________________
Medication shall be administered from: ________________________________to________________________________
Month I Day / Year Month I Day I Year
Prescriber’s Name/Title:_______________________________________
(Type or print)
Telephone: _______________________FAX: _____________________
Address:___________________________________________________
Prescriber’s Signature: _________________________Date:__________
(Original signature or signature stamp ONLY)
(Use for Prescriber’s !ddress Stamp)
PARENT/GUARDIAN AUTHORIZATION
I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/we have
legal authority to consent to medical treatment for the student named above, including the administration of medication at school. I/We
understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded.
I/We authorize the school nurse to communicate with the health care provider as allowed by HIPAA.
Parent/Guardian Signature: _______________________________________________________ Date: ______________________
Home Phone #: _____________________ Cell Phone #: _______________________ Work Phone #: _______________________
SELF CARRY/SELF ADMINISTRATION OF MEDICATION AUTHORIZATION/APPROVAL
Self carry/self administration of medication (including emergency medication) may be authorized by the prescriber and must be approved by
the school nurse according to the School Nurse Program medication policy.
Prescriber’s authorization for self carry/self administration of medication:_______________________________________________
Signature Date
School RN approval for self carry/self administration of medication: ___________________________________________________
Signature Date
Order reviewed by the school RN: _____________________________________________________________________________
Signature Date
Medication Administration 13 2014
____________________________________________________________
____________________________________ _____________________ ________________________ ___
SCHOOL NURSE PROGRAM
Medication Inventory for Controlled Substances
Name of
Student_________________________________________________________________
School______________________________ Grade____________ School Year_________
Medication and Dosage:
Directions for using this form on reverse side. TWO ADULTS MUST COUNT AND INITIAL
Date Time
New
Amount
Received
Since Last
Count
Plus
Previous
Actual
Balance
Total
Minus
Amount
Given
Expected
Balance
Actual
Balance
C =
Correct
E =
Error
Initials
Remarks
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
+
-
Signature and Initials of Persons Counting Controlled Substances:
Signature Initials Date
Medication Administration 14 2014
___________________ _____________
INCIDENT REPORT
I. Identifying Information:
___________________________________
Reported by: Employee Name and Position
_________________________
School
_____________________________
Student Name
_________________________
Birthdate
Address
II. Description of Incident:
_____________
Date
____________
Time
_________________________
Location of Incident
Witness(es) Name(s) and Position
Narrative Description of Occurrence:
(Continue on separate page, if necessary).
Disposition:
Signature Date
III. Reported To:
1. _____________________ _____________ _____________ _____________
Supervisor Date Time By
2. _____________________ ___________ _____________________________
School Administration Date Time By
3. _____________________ ________________________________________
Student’s Parent Date Time By
4. _______________________________________________________________
Student’s Physician Date Time By
Medication Administration 15 2014
Medication Administration Daily Log (To be completed for each medication)
School Year ______________________
Name of Student________________________________ Date of Birth ________________ Sex _____ Grade/Home Room (or Teacher) _________________________________________
Name of School _____________________________________________________________
Name and Dosage of Medication______________________________________ Route ________ Frequency __________ Time(s) Given in School _____________________
Directions: Initial with time of administration; a complete signature and initials of each person administrating medications should be included below.
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
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
INITIAL SIGNATURE CODES*
1. ________ __________________________________
(A) Absent (O) No Show
2. ________ __________________________________ (E) Early Dismissal (W) Dosage Withheld
3. ________ __________________________________ (F) Field Trip (X) No School (e.g. holiday, weekend, snow day, etc.)
4. _______ __________________________________ (N) No Medication Available
Use reverse side for reporting significant information (e.g. observations of medication’s effectiveness, adverse reactions, reason for omission, plan to prevent future “no shows”).
Medication Administration 16 2014
Medication Administration 18 2014
HIPAA-Compliant Authorization for Exchange of Health and Education Information
Patient/Student Name: Date of Birth:
I hereby authorize [insert health care provider name and title]
and [insert name and title of school official] to exchange
health and education information/records for the purpose listed below.
[insert address and telephone of school/school district]
[insert address and telephone of health care provider]
Description
The health information to be disclosed consists of:
The education information to be disclosed consists of:
Purpose: This information will be used for the following purpose(s) (circle all that apply):
1. Educational evaluation and program planning
2. Health assessment and planning for health care services and treatment in school
3. Medical evaluation and treatment
4. Other:__________________________________________________________________________________
Authorization
This authorization is valid for one calendar year. It will expire on [insert date]. I understand that I
may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I
recognize that health records, once received by the school district, may not be protected by the HIPAA Privacy
Rule but will become education records protected by the Family Educational Rights and Privacy Act. I also
understand that if I refuse to sign, such refusal will not interfere with my child’s ability to obtain health care;
Parent Signature Date
Student Signature* Date
*If a minor student is authorized to consent to health care without parental consent under federal or state law,
only the student shall sign this authorization form. In Michigan, a competent minor, depending on age, can
consent to outpatient mental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, and
reproductive health care services.
Copies: Parent or student*
Physician or other health care provider releasing the protected health information
School official requesting/receiving the protected health information
Medication Administration Skills Checklist
Staff Person Trained/Position_____________________________________Initials______________
School Nurse/RN_____________________________________________Initials________________
Dates
Procedure Guideline
Demonstrate/
Explain or
Proficient
Return
Demonstration
Demonstrate/
Explain or
Proficient
Return
Demonstration
Demonstrate/
Explain or
Proficient
Return
Demonstration
Comments/School Nurse initial/Staff
initial (N/A if non-applicable)
Washes hands before and after procedure.
Gives proper dose of medication at proper
time. States 5 Rights.
Compares labeled medication container
with written order.
Reads label 3 appropriate times.
Checks student identity with name on label.
Checks expiration date on label.
Explains procedure to student if necessary.
Documents medications given correctly.
Maintains security of medication area.
Describes proper actions for medication
refusal, field trip, medication error.
States appropriate times/situations for
notification of school nurse.
Emergency Medications
Epipen:
States symptoms of allergic reaction, location
of medication and emergency plan.
Demonstrates with trainer correct procedure
for administration.
States follow-up procedures.
Glucagon:
States symptoms of hypoglycemia, location of
medication and emergency plan.
Demonstrates mixing of medication in
syringe.
Demonstrates proper injection technique,
using correct site.
States follow-up procedures.
Diastat:
States understanding of when to use this
medication, location of medication and
emergency plan.
Demonstrates proper positioning of child,
procedure for administering medication.
States follow-up procedures.
Medication Administration 19 2014
_________________________________________ _________________________
_________________________________________ __________________________
Training/Supervision of School Personnel Administering Medication
____________________________________has been given training to administer medications
according to School Nurse Program’s policy and procedures; S/he has demonstrated knowledge and
understanding of the policies and procedures listed above.
RN Signature Date
I have been instructed in the School Nurse Program’s medication policy and administration
procedures. I understand that I am to administer medications to students according to these
procedures and as delegated to me by the school nurse. I understand that I am to report immediately
to the school nurse any new orders, change in medication orders, changes in a student’s health
status, and discovery of a medication error. I understand that I may not delegate this task to any
other person.
School Staff Signature Date
Medication Administration 20 2014
MEDICATION AUDIT TOOL
School________________________
Date______________
Secretary________________________________
Secretary____________________________________
Grade(s)________________ Audit Time Period__________________ School Nurse_________________________________
Student initials
COMPLIANCE
Total Percent
Authorization for Medication signed by
both parent and physician
Medication label and Authorization Form
in agreement
Expiration date on medication container
label not expired
Average percent compliant: (sum of
total column ÷ 27)
SECURITY
Total Percent
Medication in locked container
Medication and manual in same area
Average percent secure: (sum of
total column ÷ 18)
DOCUMENTATION
Total Percent
Individual medication log for each
medication (exclude self-medicate)
Initials and signature lines completed by
each person administering meds
Correct name, dosage & time on
medication log
All boxes filled with initials or
appropriate code
Medication changes documented
correctly (new log started)
Number of doses missed (do not add
to total column to figure percent)
Errors corrected properly
All documentation done in ink only
Average percent documented: (sum
of total column ÷ 49)
Total number of students with orders for inhalers________ Kept in office_________ Self carry_________
Total number of students with orders for Epi Pens________ Kept in office_________ Self carry_________
Total number of daily medications ordered__________ Total number of PRN medications ordered___________
The nurse reviewed this audit with me on _____________________ Signed _______________________________
NOTE: √=No errors in Medication Review X=Errors noted in Medication Review
SM=Self-Medicate NM=No medication available
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Medication Administration 21 2014
_____________________________________________
MEDICATION AUDIT REPORT
Dear ___________________________________________ , Principal
School: _________________________________________
Date: __________________________________________
From: School Health Services
Topic: Medication Review
The following information is a summary of the recent review conducted on medication administration at your school. We hope this
information will be helpful for you and your staff to safely administer medication during school hours.
If you have specific questions regarding problem areas that are identified, please see your school nurse. Thanks again
for working with us to accomplish this services.
I. Compliance (authorization form signed, bottles matching, etc.) _________%
II. Security (medication in locked container/cabinet) _________%
III. Documentation (all documentation on the log form) _________%
IV. Other:
Number of students on medication at your school _________
Number of teachers giving medication at your school __________
V. Recommendations:
School Nurse
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Medication Administration 22 2014
