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The State of Louisiana Medication Order form is a crucial document designed to ensure the safe administration of medication to students during school hours. This form requires completion by licensed prescribers from Louisiana, Texas, Arkansas, or Mississippi, and is structured in three distinct parts to streamline the process. The first section mandates that a parent or legal guardian provides essential details about the student, including their name, birthdate, school, and grade, alongside a signature to authorize the medication order. The second part is dedicated to the licensed prescriber, who must outline the relevant diagnosis, the student's general health status, and specific medication details, including dosage, administration route, and frequency. Importantly, this section also emphasizes that medications should be limited to those that cannot be given before or after school hours, with special circumstances requiring school nurse approval. The prescriber must also note any potential side effects, contraindications, and other medications the student may be taking. Lastly, the third part addresses self-administration of medications, particularly for students with conditions like asthma, allowing for a tailored approach to individual needs. This comprehensive structure not only facilitates clear communication among caregivers, prescribers, and school personnel but also prioritizes student safety and well-being in the educational environment.

State Of Louisiana Medication Order 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

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Documents used along the form

The State of Louisiana Medication Order form is an essential document for ensuring that students receive necessary medications during school hours. However, several other forms and documents often accompany this order to facilitate communication and compliance among parents, guardians, and school personnel. Here are five commonly used documents:

  • Parental Consent Form: This form is required to obtain permission from a parent or legal guardian for a student to receive medication at school. It ensures that the school has the necessary authorization to administer the prescribed treatment.
  • Emergency Action Plan: This document outlines specific procedures to follow in case of a medical emergency related to a student’s health condition. It includes critical information about the student’s diagnosis, potential triggers, and emergency contacts.
  • Health History Form: This form collects comprehensive information about a student’s medical history, including allergies, chronic conditions, and previous hospitalizations. It helps school staff understand the student’s health needs better.
  • Medication Administration Record (MAR): This record tracks when and how medications are administered to students at school. It serves as a log for school personnel to ensure that medications are given according to the prescribed schedule.
  • Ohio Operating Agreement Form: For businesses in Ohio, the comprehensive Ohio Operating Agreement resources provide crucial guidelines for structuring and managing your LLC effectively.
  • Self-Administration Agreement: This form is used when a student is permitted to carry and self-administer their medication, such as an inhaler. It confirms that the student has been trained and is competent in managing their medication independently.

These documents work together with the State of Louisiana Medication Order form to create a comprehensive approach to student health management in schools. By ensuring all necessary paperwork is completed, schools can provide safe and effective care for students with medical needs.

Key takeaways

When filling out and utilizing the State of Louisiana Medication Order form, it is crucial to adhere to specific guidelines to ensure the process runs smoothly and effectively. Here are some key takeaways to consider:

  • Complete All Sections: The form has distinct parts that must be filled out by both the parent or legal guardian and the licensed prescriber. Omitting any information could delay the medication administration process.
  • Obtain Necessary Consent: A separate parental or legal guardian consent form is required. This form can be obtained from the school nurse, and it must be submitted alongside the medication order.
  • Medication Timing: Medications should only be ordered for administration during school hours if they cannot be taken before or after school. If special circumstances arise, approval from the school nurse is necessary.
  • One Order Per Medication: Each medication must have its own order form. If changes to the medication directions occur, a new order form must be submitted to reflect those changes.
  • Self-Administration Protocol: For students who may carry and self-administer medications, specific criteria must be met. The prescriber must confirm whether the student is a candidate for self-administration training.
  • Legibility and Communication: Ensure that all information is legible. If faxing the order, it may be necessary to send the original form to the school to avoid any misunderstandings.

By following these guidelines, parents, guardians, and prescribers can help ensure that students receive their medications safely and effectively while at school.

↓ State Of Louisiana Medication Order PDF