Are you confused about Louisiana Medication Order forms? We understand that the medical industry has its own set of rules and processes, which can take time to get used to. Now, if you are in the state of Louisiana and looking for more information on ordering medication then this blog post is a great place to start. Here we will examine all aspects of filling out a Louisiana Medication Order Form as well as discussing applicable laws and regulations associated with these types of orders. By understanding key components such as medications legally available in the State, physician's prescription requirements and other related topics; you can ensure accurate completion while adhering to state regulations. Read on for more details!
Question | Answer |
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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 |