In navigating the complexities of administering medication to students within the school setting, the State of Louisiana has implemented a structured Medication Order form, designed with a comprehensive approach to ensure the well-being and safety of students requiring medication during school hours. This multifaceted document, meticulously crafted to be filled out by licensed prescribers from Louisiana, Texas, Arkansas, or Mississippi, addresses a broad swath of important factors, ranging from the student's personal information and health status to detailed medication instructions. The form is methodically divided into distinct sections, beginning with the essential step of obtaining parental or legal guardian consent, a foundational aspect that underscores the collaborative approach between healthcare providers, school authorities, and families. The succeeding section delves into the medical specifics, requiring precise information such as the diagnosis, medication details including strength, dosage, and frequency, and any potential side effects or contraindications, ensuring that all parties are well-informed. A key provision within this document highlights that medication orders are generally restricted to those medications that cannot be feasibly administered outside of school hours unless sanctioned by the school nurse, emphasizing the priority of student safety and the educational environment. Additionally, the form accommodates students capable of self-administering their medication, such as inhalers for asthma, contingent on the prescriber’s endorsement and a substantive assessment of the student’s self-administration capabilities. This careful orchestration of information and permissions encapsulated in the State of Louisiana Medication Order form represents a crucial tool in the management of student health, facilitating a smooth collaboration between health professionals, educational institutions, and families.
| Question | Answer |
|---|---|
| Form Name | State Of Louisiana Medication Order Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | louisiana medication form, louisiana medication form pdf, state of louisiana medication order form, louisiana state public school medication form |
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): ___________________
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Check Route: ❑ By mouth ❑ By inhalation ❑ Other __________________________ |
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Frequency ____________________________ Time of each dose _____________________ |
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___________________________________________________________________________ |
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School medication orders shall be limited to medication that cannot be administered before or after |
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school hours. Special circumstances must be approved by school nurse. |
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5. |
Duration of medication order: ❑ Until end of school term |
❑ Other ____________________ |
6.Desired Effect: _____________________________________________________________________
7.Possible
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 |
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1. Is the student a candidate for |
❑ 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
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 |