1. What you need to know about Medication Administration and Documentation in the school
Presented by…
Madison County School Nurses
Laura Kirkpatrick, RN, BSN
Teresa Nolan, RN, BSN
Kathey Lee, RN, BSN
Michele H Bailey, RN, ADN

2. Designated School Personnel's Responsibilities
For Administering and Documenting Medication Administration

3. Related NC General Statutes: 115C-307(c) & 115C-375.2

4. Related NC General Statutes: 115C-307(c) & 115C-375.2
All medications administer by school personnel during school hours must be prescribed by a licensed health care provider & have a written request/permission signed by the parent/legal guardian.
Students needing inhalers and/or epi-pens have the right to possess and self-administer under certain parameters.

5. Policy #6125-Administering Medicines to Students
States the procedure/paperwork needed to be able to give individual students medications at school.

6. Student Health Services Policy #6120
Employees designated to provide health services must receive appropriate training
Health Manuals prepared by state departments will be followed in developing appropriate procedures

7. NC School Health Program Manual
Medication Administration Info can be found in Section E2, beginning on page 248.

8. NC School Health Program Manual *Medication Administration -Key Points
SN is to train, delegate, supervise, and audit
All new meds are to be reviewed by SN
School’s must keep a record of all mediations given at school until the student is 29 years of age.

9. To avoid making errors, always follow the “6 Rights” and the “3 Checks” of medication administration.

10. The 3 Checks
Always check the medication label against the written order or medication administration record (MAR) 3 times before giving the medication to the student.
1st Check: Getting medication out of the drawer or cabinet
2nd Check: When you are pouring the medication or putting pills in the cup
3rd Check: As you put the medication away and immediately before giving to the student.

11. THE 6 RIGHTS Right Child Right Medication Right Dosage Right Time/Day
Right Route
(Write) Documentation

12. Right Child
It is a good idea to take a picture of each child that you will be giving medication to and place it with their MAR
Double check to see if you have the right child by having the student state their name
(Both of these will help you to identify the right student, especially if you are not the person that usually gives the medications)

13. Right Medication
Always compare the label on the bottle with the medical information sheet (MAR) that is signed by the physician.
Do this at least 3 times by following the 3 check method listed earlier.

14. Right Dosage
Always double check the label on the bottle with the dosage on the medication administration record (MAR) and/or physician’s authorization sheet

15. Right Time (and date)
Check the medication log for the time it is to be given.
Up to 30 minutes before or after the prescribed time is acceptable
Sometimes medications are to be given only on certain days of the week. Check the MAR and the bottle.

16. Right Route
Check the medication log and pharmacy label to be sure it is to be given by mouth or to be dropped in the eye, for example.
Double, triple check
Contact the nurse if any uncertainty is present

17. Right Documentation (Write)
You must correctly document the previous five rights to prove exactly what has been done. This actually counts as the “6th Right” (Right Documentation).

18. General Principles of Documentation
Sign every entry
(If using initials, your full signed name must appear on the same page)
Be legible, factual, concise, and complete
Document promptly and always in ink (black ink is preferable)
Note date and time of care on all documents
Use only authorized abbreviations
Correctly identify late entries as such

19. General Principals of Documentation cont.
Correct all mistakes by crossing though the error with a single line, write error above entry, and initial the correction
Do Not Ever Erase or Alter Previous Written Notes (NO WHITE OUT)
Document exact quotes. Noncompliance, and missed medications/procedures

20. Notify your Nurse with the following…
When a student is new to a medication. DO NOT GIVE a new medication until it has been reviewed by your Nurse
When you are about to administer a medication that is new to you
When you suspect an unwanted reaction to a medication
When you are unsure why a student is taking a certain medication
If you are unsure of the dosage
If you are unfamiliar with the prescribed medication

21. What is your Nurse’s role?
Audit and review the documentation and administration techniques with designated staff to ensure safety and accuracy.
Ensure that the right dose and right medicine is prescribed for the student (doctors and pharmacies make mistakes too)
Be knowledgeable about medications and be available for questions or concerns from staff, students, or family

22. Nurse’s role cont…
Advocate (Ensure that meds are handled in a way that best meets the students’ needs)
Advise staff in regards to any medication questions (Including, advise what to do when one of the “six rights” have been broken or in case of a reaction)
Staff training and education

23. Medication Authorization Form
This is the form that we need completed by parent and MD in order to be able to give any medication at school for a student. Feel free to share this link and/or let folks know that it is on our MCS website.
Fax Numbers: Brush Creek Elem , Hot Springs Elem , Laurel Elem , Mars Hill Elem , Madison Middle , Madison High

24. Medication Administration Record (MAR)
This is the form that is used to record what/when a student received medication at school.

25. Self-Carry Contract
This is the form used if a parent & doctor want the student to carry a potential emergency medication themselves

26. Medication Administration Incident Report
This is the form to complete if there has been an error in medication administration. This protects you, the school, and the student.

27. Questions?