Holy Trinity Roman Catholic
Separate School Division
502 Sixth Avenue North East
Moose Jaw, SK S6H 4P8
Sample Form
Daily Medication Record
|
Student Name
|
Date of Birth
|
|
School
|
|
|
Medication Name:
|
Dose: |
|
Route of Administration:
|
Time/Frequency: |
|
Start Date:
|
Stop Date: |
|
Other Directions:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
|
|
Directions:
· Only one medication per record
· Initials of personnel administering medication indicates that the person prepared, administered, and witnessed that it was taken.
· Indicate absent, refused, or missed doses.
· Insert date in upper left corner of each box.
· Full signature must appear on each page that initial appear.
|
Month |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Signature Initials
_____________________________________ ___________
_____________________________________ ___________
_____________________________________ ____________