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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