Medication Administration
Monthly Medication Administration Record (p.1of 2) - Medicaid Compliant
Student Name: DOB: School/District: Grade:
Parent/Guardian: Phone: Physician/NP/PA: Phone:
Medication Order: Medication Name/Dose: Route:
Order start date (MM/DD/YY): Order expiration date (MM/DD/YY):
|Date |Time-in |Time-out |Dose |Exception Code |Reaction |Signature/title |*CPT/Unit |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
|Date |Time-in |Time-out |Dose |Exception Code |Reaction |Signature/title |*CPT/Unit |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
|Date |Time-in |Time-out |Dose |Exception Code |Reaction |Signature/title |*CPT/Unit |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
|Date |Time-in |Time-out |Dose |Exception Code |Reaction |Signature/title |*CPT/Unit |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
| | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | |
*Medication Administration Procedure Code: CPT T1002 = RN services up to 15 min. or CPT T1003 = LPN services up to 15 min.
To be completed by Service Practitioner (School Nurse/RN): NOTE: LPN must use supervising RN’s NPI number
Name: ______________________________________ Title: _______ NPI number: ___
To be completed by Billing Provider (School District, County or §4201 School): NPI Number: _________________________________
Additional Documentation
Monthly Medication Administration Record (p.2 of 2)
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