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The State of Louisiana Medication Order form serves as a crucial document for ensuring that students who require medication during school hours receive the appropriate care. Designed to be completed by licensed prescribers from Louisiana, Texas, Arkansas, or Mississippi, this form is structured in three distinct parts, each serving a specific purpose. The first section is dedicated to the parent or legal guardian, who must provide essential information about the student, including their name, birthdate, and school details. This section also requires the guardian's signature, affirming consent for the medication administration. In the second part, the licensed prescriber outlines vital information such as the student’s diagnosis, general health status, and specific medication details, including dosage, frequency, and route of administration. It is important to note that the form limits medication orders to those that cannot be given before or after school, ensuring that all protocols are followed for the student’s safety. Additionally, the prescriber must indicate any potential side effects and contraindications, as well as other medications the student may be taking outside of school. The third part addresses special circumstances, allowing for students to self-administer certain medications, like inhalers, under specific conditions. This comprehensive approach not only safeguards the well-being of students but also facilitates clear communication among parents, healthcare providers, and school staff.

Document Example

STATE OF LOUISIANA

MEDICATION ORDER

TO BE COMPLETED BY LA, TX, AR, OR MS LICENSED PRESCRIBER

(In most instances, medications will be administered by unlicensed personnel.)

PART 1: PARENT OR LEGAL GUARDIAN TO COMPLETE.

Student’s Name ______________________________________________ Birthdate _______________

School _____________________________________________________ Grade _________________

Parent or Legal Guardian Name (print): ________________________________________________

Parent or Legal Guardian Signature:______________________________________________ Date:__________

(Please note: A parental/legal guardian consent form must also be filled out. Obtain from the school nurse.)

PART 2: LICENSED PRESCRIBER TO COMPLETE.

1.Relevant Diagnosis(es): ______________________________________________________________

2.Student’s General Health Status: _______________________________________________________

3.Medication: ________________________________________________________________________

4.Strength of medication: ___________________ Dosage (amount to be given): ___________________

 

Check Route: ❑ By mouth ❑ By inhalation ❑ Other __________________________

 

Frequency ____________________________ Time of each dose _____________________

 

___________________________________________________________________________

 

School medication orders shall be limited to medication that cannot be administered before or after

 

school hours. Special circumstances must be approved by school nurse.

5.

Duration of medication order: ❑ Until end of school term

❑ Other ____________________

6.Desired Effect: _____________________________________________________________________

7.Possible side-effects of medication: ____________________________________________________

8.Any contraindications for administering medication: ________________________________________

_________________________________________________________________________________

9.Other medications being taken by student when not at school:

_________________________________________________________________________________

_________________________________________________________________________________

10.Next visit is: _____________________________________

___________________________________________________________________________________

Prescriber’s Name (Printed)AddressPhone and Fax Numbers

__________________________________________________________________________________________

Prescriber’s Signature

Credential (i.e., MD, NP, DDS)

Date

Each medication order must be written on a separate order form. Any future changes in directions for medication ordered require new medications orders. Orders sent by fax are acceptable. Legibility may require mailing original to the school. Orders to discontinue also must be written.

PART 3: LICENSED PRESCRIBER TO COMPLETE AS APPROPRIATE.

Inhalants / Emergency Drugs

Release Form for Students to be Allowed to Carry Medication on His/Her Person

Use this space only for students who will self-administer medication such as asthma inhaler.

 

1. Is the student a candidate for self-administration training?

❑ Yes

❑ No

2.Has this student been adequately instructed by you or your staff and demonstrated competence in self- administration of medication to the degree that he/she may self-administer his/her medication at school, provided that the school nurse has determined it is safe and appropriate for this student in his/her particular

school setting? ❑ Yes ❑ No

3. If training has not occurred, may the school nurse conduct a training program? ❑Yes ❑ No

_____________________________________________________________________________

Licensed Provider’s Signature

Date

Dos and Don'ts

When filling out the State of Louisiana Medication Order form, it’s crucial to ensure accuracy and compliance with guidelines. Here’s a list of things you should and shouldn’t do:

  • Do fill out all required sections completely, including the student’s name and birthdate.
  • Do ensure that the parent or legal guardian signs the form, confirming their consent.
  • Do provide detailed information about the relevant diagnosis and general health status of the student.
  • Do specify the medication's strength, dosage, and frequency clearly.
  • Do indicate any possible side effects and contraindications associated with the medication.
  • Don't leave any sections blank, as incomplete forms may lead to delays in medication administration.
  • Don't forget to obtain a parental/legal guardian consent form from the school nurse, as it is required.
  • Don't use the same order form for multiple medications; each medication must have its own order form.
  • Don't assume that verbal instructions are sufficient; all orders must be written and signed by the licensed prescriber.

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Detailed Instructions for Filling Out State Of Louisiana Medication Order

Filling out the State of Louisiana Medication Order form is a crucial step in ensuring that a student receives the necessary medication during school hours. This process involves multiple parties, including parents or legal guardians and licensed prescribers. To accurately complete the form, follow the steps outlined below.

  1. Begin with Part 1, where the parent or legal guardian must provide the student's name, birthdate, school, and grade.
  2. Print and sign the name of the parent or legal guardian in the designated area.
  3. Include the date of signing in the appropriate field.
  4. Note that a separate parental/legal guardian consent form is also required; obtain this from the school nurse.
  5. Move to Part 2, where the licensed prescriber will fill in relevant medical information. Start with the relevant diagnosis or diagnoses.
  6. Describe the student’s general health status in the provided space.
  7. List the medication that is to be administered.
  8. Indicate the strength of the medication and the dosage amount to be given.
  9. Select the route of administration by checking the appropriate box (e.g., by mouth, by inhalation, or other).
  10. Specify the frequency of administration and the time of each dose.
  11. Indicate the duration of the medication order by checking the appropriate box (until the end of the school term or other).
  12. Describe the desired effect of the medication.
  13. List any possible side effects associated with the medication.
  14. Note any contraindications for administering the medication.
  15. Provide information about any other medications the student is taking when not at school.
  16. Specify the date of the next visit with the prescriber.
  17. Print the prescriber’s name, address, phone, and fax numbers in the designated fields.
  18. Sign the form and indicate the prescriber’s credential (e.g., MD, NP, DDS) along with the date of signing.
  19. Remember that each medication order must be written on a separate form, and any changes in medication directions require a new order.
  20. In Part 3, if applicable, answer the questions regarding self-administration of medication for students who may need to carry their inhalers or emergency medications.
  21. Finally, ensure that the licensed provider signs and dates this section if applicable.

Documents used along the form

The State of Louisiana Medication Order form is an essential document for managing student medications in schools. Alongside this form, several other documents may be necessary to ensure proper medication administration and compliance with regulations. Below is a list of related forms that are commonly used.

  • Parental Consent Form: This form requires a parent or legal guardian's signature to authorize the administration of medication to their child during school hours.
  • Emergency Contact Form: This document provides the school with important contact information for parents or guardians in case of an emergency involving the student.
  • Health History Form: This form gathers detailed information about the student's medical history, allergies, and any ongoing health conditions that may affect medication administration.
  • Medication Administration Record (MAR): This record tracks the administration of medications to students, including dates, times, and dosages given.
  • Rental Application Form: To assist landlords and potential tenants alike, fill out the necessary rental application form quickly for a seamless rental experience.
  • Inhalant/Emergency Drugs Release Form: This form allows students to carry and self-administer medications such as asthma inhalers, provided they meet specific criteria.
  • Medication Discontinuation Order: A written order from a licensed prescriber is required to discontinue any medication previously authorized for a student.
  • School Nurse Assessment Form: This document is used by the school nurse to evaluate the student's health status and determine the appropriateness of medication administration.
  • Training Documentation for Self-Administration: This form verifies that a student has been trained and is competent to self-administer their medication under the supervision of the school nurse.

Understanding these forms and their purposes can help streamline the process of managing student medications effectively. Proper documentation ensures that students receive the necessary care while at school.

Your Questions, Answered

What is the purpose of the Louisiana Medication Order form?

The Louisiana Medication Order form is used to ensure that students receive their prescribed medications during school hours. It is designed to be filled out by both a parent or legal guardian and a licensed prescriber. This form helps schools manage medication administration safely and effectively.

Who needs to complete the form?

The form consists of three parts:

  1. The parent or legal guardian must complete Part 1.
  2. A licensed prescriber, such as a doctor or nurse practitioner, must fill out Part 2.
  3. Part 3 is also for the licensed prescriber, specifically for students who may need to carry and self-administer their medication.

The parent or legal guardian must provide the following details:

  • The student's name and birthdate
  • The school and grade
  • The name and signature of the parent or legal guardian
  • The date the form is completed

Additionally, they must complete a parental consent form, which can be obtained from the school nurse.

What does the licensed prescriber need to include?

The licensed prescriber must provide detailed information about the student’s diagnosis, health status, medication, dosage, frequency, and any possible side effects. They also need to indicate the duration of the medication order and any other medications the student is taking.

Can medications be administered outside of school hours?

No, the school medication orders are limited to medications that cannot be given before or after school hours. If there are special circumstances, these must be approved by the school nurse.

What if changes are needed in the medication order?

If there are any changes in the directions for the medication, a new medication order must be written. Each medication order should be on a separate form. Orders can be sent by fax, but the original may need to be mailed for legibility.

Common mistakes

Filling out the State of Louisiana Medication Order form can be straightforward, but several common mistakes can lead to delays or complications. One significant error is failing to provide complete information in the Student’s Name and Birthdate sections. Omitting any part of this information can cause confusion and hinder the medication administration process. It is essential to ensure that the student’s name is spelled correctly and that the birthdate matches the records.

Another frequent mistake occurs when parents or legal guardians neglect to sign the form. The Parent or Legal Guardian Signature is a critical component of the document. Without it, the school cannot proceed with administering the medication. Additionally, the date of the signature must be included. Missing this detail can lead to misunderstandings about when consent was granted.

Inaccuracies in the Medication section can also pose serious risks. Parents must ensure that the medication name is correct and that the dosage is clearly indicated. Ambiguities in this section can lead to misadministration, which may endanger the student's health. It is crucial to double-check that the strength of the medication and the dosage match the prescriber's instructions.

Another common oversight is neglecting to specify the Route of administration. The form provides options such as "By mouth" or "By inhalation," and it is vital to check the appropriate box. Failing to do so can result in the medication being administered incorrectly. Furthermore, the Frequency and Time of each dose must be clearly stated to ensure that the medication is given as prescribed.

Lastly, individuals often overlook the requirement for a separate order form for each medication. If multiple medications are needed, each must be documented on its own form. Additionally, any changes in medication directions require new orders. This oversight can create confusion and disrupt the medication regimen. Always ensure that each medication order is submitted correctly and promptly.

Misconceptions

1. The form can be completed by anyone. This is incorrect. Only licensed prescribers from Louisiana, Texas, Arkansas, or Mississippi can fill out the medication order form. It is essential that a qualified professional assesses the student’s health needs.

2. Medications can be administered at any time during school hours. This misconception arises from a misunderstanding of the rules. Medications listed on this form can only be given during school hours if they cannot be taken before or after school. Special cases must be approved by the school nurse.

3. Parents do not need to sign anything. Parents or legal guardians must complete and sign the first part of the form. This signature is crucial as it provides consent for the medication to be administered to the student.

4. One medication order form can cover multiple medications. Each medication must have its own separate order form. This ensures clarity and proper documentation for each medication the student is taking.

5. Faxed orders are not acceptable. In fact, faxed orders are permitted. However, if legibility is an issue, the original order may need to be mailed to the school. Clarity in the order is essential for safe administration.

6. The form is only for long-term medication. This is a common misunderstanding. The form can be used for both short-term and long-term medications, but the duration must be specified by the prescriber.

7. The school nurse has no role in the medication administration process. This is false. The school nurse plays a vital role in approving special circumstances and ensuring that medications are administered safely and appropriately. Their expertise is crucial in managing student health needs.

Document Attributes

Fact Name Details
Governing Law The medication order form is governed by Louisiana Revised Statutes, Title 17, Section 436.1.
Intended Users This form is to be completed by licensed prescribers from Louisiana, Texas, Arkansas, or Mississippi.
Parental Involvement A parent or legal guardian must complete the first part of the form, providing necessary information and consent.
Medication Administration In most cases, medications will be administered by unlicensed personnel under the supervision of a school nurse.
Medication Restrictions School medication orders are limited to medications that cannot be given before or after school hours.
Self-Administration Students may be allowed to carry certain medications, like inhalers, if they meet specific criteria set by the prescriber and school nurse.
Separate Orders Each medication order must be written on a separate form. Changes require new orders.
Fax Orders Orders can be sent by fax, but original copies may need to be mailed for legibility.