Medication Administration
Monthly Medication Administration Record
Student Name | |
DOB | |School/ District | |
Grade | | |
Medication | |
Dose | |
Route | |ICD-10 Code |
__ __ __ __ __ | |Parent/ Guardian | |
Phone | |Physician/ NP/PA | |
Phone | | |
Order start date (MM/DD/YY): Order expiration date (MM/DD/YY): ( ICHP on File
Date |Time-in |Time-out |Time Given |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 | | | | | | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | | |Date |Time-in |Time-out |Time Given |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 | | | | | | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | | |Date |Time-in |Time-out |Time Given |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 | | | | | | | | |( Out of med. ( Absent ( Refused ( Field trip ( Other (see notes) |( Adverse (see notes) ( Appropriate | | | |Date |Time-in |Time-out |Time Given |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 | | | | | | | | |( 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 Attending Provider (School Nurse/RN): NOTE: LPN must use supervising RN’s NPI number
Name: ______________________________________ Title: _______ NPI number: ___ ________
Name: ______________________________________ Title: _______ NPI number: ___ ________
Name: ______________________________________ Title: _______ NPI number: ___ ________
Name: ______________________________________ Title: _______ NPI number: ___ ________
To be completed by Billing Provider (School District, County or §4201 School): NPI Number: __________________________________________________
Student Name:____________________________________________________________DOB:________________ Page 2.
Additional Documentation
Monthly Medication Administration Record (p.2 of 2)
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All documentation should include date, time, signature, and title.
This sample form is located at: in the Forms | Notifications – updated February 2017
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