Month/Year:
Child’s Name:
MEDICATION LOG
All medications, prescription and nonprescription must be documented. Prescription Medication Nonprescription Medication
If Nonprescription, is child on prescription medication? Yes No If YES, list date OTC drugs were approved by an MD/RPh: __
Medication:
Reason for administering:
Foster Family: Date Filled: Expiration:
Physician: Prescription #:
Medication Allergies: Strength:
Directions:
QD=1/day BID=2/day TID=3/day QID=4/day QHS=bedtime PRN=as
R=refused S=school Form:
Date Refilled: Expiration:
Strength: Start Count: Directions:
Form: pill liquid spray inhaler lotion/cream shot
Signature and Initial of anyone who is authorized to administer medication, including respite providers:
If a child is on an approved self-medication program, the child must report the medication to a caregiver, who then must document. Document the following incidents below:
1. Any missed medications and the reason, including if the child refused to accept medication
2. Any other medication incidents such as adverse reaction or change in behavior (complete Medical Incident Log).
3. School or Respite (Document amount of medication given to school/respite provider)
4. Medication discontinued? If YES, who approved and date discontinued. Also document how discontinued medication was discarded in accordance with TBF Policy.
5. Medication changed? If Yes, who approved and date changed
6. *CHILDREN SHOULD NOT MISS ANY DOSES OF MEDICATION – If a dose is missed, contact your SSW or director immediately and document your conversation below.
If a caregiver finds a medication error, the caregiver must contact a healthcare professional immediately and follow the heal thcare professional’s recommendations and complete Medical Incident Report.
Date Medication-Related Incident
Document Child’s Response to
If Negative, Why?
Document all scheduled and unscheduled appointments for medication monitoring below. If a visit is cancelled, explain why.
Date
Scheduled and Unscheduled Appointments
Document if any medicationis given to another person todispense to thefoster child (such as camp counselor, mother of a child the foster child is spending the night with, and/or school nurse, etc)
Date
Name and Amount Given
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