ࡱ> k y&bjbjȬ 7b΢,j΢,jk  77777KKK8lKQ"Zsddd!!!!!!!$a'!7ddddd!77 "PPPdF77 pPd!PPP0l?TPp !"0Q"P'<'PP'7d ddPddddd!!:dddQ"dddd'ddddddddd Y : Monthly Medication Administration Record Student Name DOBSchool/ District Grade Medication Dose Route ICD-10 Code __ __ __ __ __Parent/ Guardian PhonePhysician/ NP/PA Phone Order start date (MM/DD/YY): Order expiration date (MM/DD/YY): ( ICHP on File DateTime-inTime-outTime GivenDoseException CodeReactionSignature/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) ( AppropriateDateTime-inTime-outTime GivenDoseException CodeReactionSignature/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) ( AppropriateDateTime-inTime-outTime GivenDoseException CodeReactionSignature/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) ( AppropriateDateTime-inTime-outTime GivenDoseException CodeReactionSignature/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 RNs NPI number Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Name: ______________________________________ Title: _______ NPI number: ___ ________ Student Name:____________________________________________________________DOB:________________ Page 2. Additional Documentation Monthly Medication Administration Record (p.2 of 2) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ All documentation should include date, time, signature, and title. 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