MEDICATION REVIEW FORM - Gates County Schools
GATES COUNTY SCHOOLS
MEDICATION AUDIT FORM
School __________________________________ Teacher(s) __________________________________________
Date ____________________________________ Medication Person(s) _________________________________
School Nurse _____________________________ ( = Compliant X = Not Compliant
STUDENT INITIALS:
| | | | | | | | | | | | | | | | | |Authorization form for each medication | | | | | | | | | | | | | | | | | |Medication locked unless self-carried, contract in place or an emergency medication | | | | | | | | | | | | | | | | | |Parental permission complete | | | | | | | | | | | | | | | | | |Physician orders complete | | | | | | | | | | | | | | | | | |Prescription medications have a pharmacy label | | | | | | | | | | | | | | | | | |Authorization form and pharmacy label match | | | | | | | | | | | | | | | | | |Demographics completed on logs | | | | | | | | | | | | | | | | | |Boxes on log completed with time and initials or coded | | | | | | | | | | | | | | | | | |Initials and complete name of med. person at bottom of log | | | | | | | | | | | | | | | | | |Completed check-in/out log for each medication | | | | | | | | | | | | | | | | | |Medication has not expired | | | | | | | | | | | | | | | | | |
Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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