Appendix D | Answers4Families

SAMPLE FORMS FOR IMPLEMENTING MEDICATION AIDE ACT IN SCHOOLS

Administering Medications to Students - Pre and Post Test
Circle the appropriate response.

T	F	1. Medication administration at school requires a parent's written consent.
T	F	2. Store medications in an unlocked cabinet in a locked school.
T	F	3. Record medication administration prior to giving medication.
T	F	4. When a student refuses to take a scheduled medication, you should report this immediately.
T	F	5. Prescription medication is over-the-counter medication.
T	F	6. Proper handwashing is very important in fighting the spread of germs.
T	F	7. It is proper to put tablets and capsules into the student's hand if you are careful.
T	F	8. Unwrap individually wrapped medications when you are ready to give the medication.
T	F	9. Measure liquid medication at eye level to assure proper dosage.
T	F	10. You may apply topical medications such as ointments, creams and lotions using your fingers if you wash your hands first
T	F	11. If you are unsure about how to administer a medication, check before administering.
T	F	12. Report any change in the student's condition.
T	F	13. The auto-injector pen may be administered through clothing.
T	F	14. Drug legislation is designed to ensure the public's safety and to regulate the manufacture and sale of drugs.
T	F	15. Any school personnel may dispense prescription medication.
T	F	16. A legal prescriber includes a pharmacist, physician, and dentist.

17.

Drugs are classified as:
A. OCT
B. Controlled substances
C. Prescription medication
D. All of the above

18.

The first action you take when you are unclear about administering a medication is:
A. Check with the student
B. Check with the prescriber
C. Do not administer the medication
D. Use judgment

19.

The record of medication administration includes:
A. Name of the student
B. Date
C. Time medication is given
D. All of the above.

20.

The student does not come for the medication on time. You should:
A. Check with the classroom teacher, attendance office, or principal
B. Call the student's parents
C. Notify the school nurse immediately
D. Call the physician

21.

A student vomits after taking medication, you report:
A. Student's name and age
B. Medicine and dosage
C. Time interval between medication administration and vomiting
D. All of the above

22.

You make a medication error. You should Immediately:
A. Report the error following school guidelines
B. Fill out an incident report
C. Induce vomiting
D. Notify the student's parents and physician

23.

To prevent the spread of germs, wash hands:

A. 1,2,5
B. 3,4,6
C. All of these
D. None of these

1. Before giving each student's medication.
2. After giving each student's medication.
3. At the beginning of the day.
4. After using the restroom.
5. Between giving each student medication.
6. After removing gloves

24.

Each time you give a medicationyou should:
A. Perform proper handwashing techniques
B. Check the "Five Rights"
C. Fill out the medication log
D. All of the above

25.

A student is taking two liquid medications. You do all except:
A. Measure the liquid using a medicine cup
B. You may mix liquid medications In the same cup
C. Hold the bottle with the label facing your palm
D. Measure dosage at the bottom of the disc

26.

Administration of eye drops includes:
A. Approach from inside the student's field of vision
B. Touch the eye with the dropper
C. After administration the student closes the eyes for a few minutes
D. Blot excess from the outside of the eye to the inside.

27.

Administration of the auto-injector medication in emergencies includes:
A. Pull off safety cap
B. Place tip on high
C. Press auto-injector against thigh until mechanism activates
D. All of the above.

28.

When administering ear drops:
A. Pull the ear up and back for children
B. Wait at least 1 minute before putting drops in the second car
C. Washing your hands it is not necessary since chances of spreading germs are minimal
D. All but C

29.

Qualified school personnel may administer medication by injection:
A. In situations were no previous training has occurred
B. In emergency situations such as allergic reactions
C. Both A and B
D. None of the above

30.

Monitoring student self-administration by inhaler does not include:
A. Exhale immediately after inhalation for medication to settle
B. Reminding the student to take medication
C. Shaking the inhaler for two seconds
D. Waiting 2 minutes before the second inhalation

31.

The role of the qualified person to administer medication includes all except:
A. Responsibility in following medication administration procedures
B. Obtain medication information from the school health plan
C. No accountability for errors
D. Know the specific instructions for each medication administered

32.

The best definition of medication is
A. A synthetic and artificial substance prepared in labs from chemicals
B. A substance to prevent, diagnose, cure, or relieve disease
C. The generic name is designated and patented by the manufacturer
D. A substance which is unlikely to produce adverse effects

33.

Reliable sources of medication include all of the following except:
A.. Phonology textbooks
B. Drug reference books
C. School Nurse
D. Pharmacist

34. List the "Five Rights" of medication administration and explain each one (10 points).

35. Name and explain what is often referred to as the "Sixth Right" of medication administration (2 points).

TEST KEY
1. T
2. F
3. F
4. T
5. F
6. T
7. F
8. T
9. T
10. F
11. T
12. T
13. T
14. T
15. F
16. F
17. D
18. C
19. D
20. A
21. D
22. A
23. C
24. D
25. B
26. C
27. D
28. B
29. B
30. A
31. C
32. B
33. A
34. Right Student - Properly identifies the student.
Right Time - Administer medication at the prescribed time.
Right Medicine - Administration of the correct medication.
Right Dose - Administration of the right amount of medication.
Right Route - Use the prescribed method of medication administration. One point each for rights and description for a total of 10 points.

35. Right Documentation - Record and report the five rights of medication administration. Include the student name, time, medication, dose, route, date, person administering, and unusual observations and circumstances. One point for the right and one point for the description for a total of 2 points.

______Total Score Possible 45 points Score 38 points = 85% mastery

Medication Administration to Students at School Self and Instructor Evaluation

Key for scoring: I = satisfactory completion 0 – unsatisfactory completion or omission

Name_________________________________________________

Date__________________________________________________

Score_________________________________________________

General Medication Administration
____ 1. Wash hands.
____ 2. Verify the authorization with the label.
____ 3. Gather necessary items.
____ 4. Check the label for name, time, medication, dose and route when picking up the container.
____ 5. Prepare the medication without touching the medication. Check the label for name, time, medication, dose and route.
____ 6. Check the label for name, time, medication, dose and route when returning the container to the locked safe place.
____ 7. Identify the student.
____ 8. Observe the student for any unusual behaviors or conditions.
____ 9. Explain the procedure to the student.
____ 10. Position the student properly for the medication administration.
____ 11. Administer the medication to the correct student.
____ 12. Administer the correct medication.'
____ 13. Administer at the correct time.
____ 14. Administer the correct dose.
____ 15. Administer by the correct route.
____ 16. Provide equipment and supplies as needed.
____ 17. Verify the student received the medication.
____ 18. Record medication administration. Record the student, medication, dose, time, route, person administering and unusual observations.
____ 19. Report unusual reactions immediately following school procedure.
____ 20. Clean, return and/or dispose of equipment as necessary.
____ 21. Wash hands.

Oral Medication Administration Tablets or Capsules
____ 1. Remove bottle cap and hold cap in one hand and -container in other hand.
____ 2. Pour the medication into the cap.
____ 3. Transfer the medication from cap to a clean container (medicine cup) and give cup to the student.
____ 4. Give with a full glass of water unless otherwise indicated.
____ 5. Verify the student swallowed the medication.
____ 6. Recap the bottle and return it to the proper place.
____ 7. Individually wrapped medications.
a. Remove or tear off number needed and place package in a clean medicine cup.
b. Remove from package and transfer into cup when student takes the medication.
Liquid or powder
____ 1. Shake container per label instructions.
____ 2. Pour liquid from side of the bottle opposite the label (hold label in palm of hand). Pour into graduated medicine cup.
____ 3. Pour medication at eye level and directly in front of eyes.
____ 4. Measure the dosage at the bottom of the disc (meniscus).
____ 5. Wipe off any medication on the outside of the container.

Topical Medication Administration
Skin Medications
____ 1. Gather necessary equipment may include: tongue blade, gauze, tape, cleansing material, cotton-tipped applicator and gloves.
____ 2. Cleanse the skin, remove previously applied medication, apply medication in a thin layer or as ordered.
____ 3. Cover skin as directed.

Eye Drops
____ 1. Gather necessary equipment: cotton balls and tissue.
____ 2. Cleanse the eye with a clean cotton ball wiping once from the inside to the outside. Use new clean cotton ball for each eye.
____ 3. Position student with head tilted back and eyes looking up. Open the eye to expose the conjunctival sac.
____ 4. Approach the eye outside the field of vision. Avoid touching the dropper tip to anything.
____ 5. Drop the medication into the sac, not on the eyeball, with the drop not falling more than 1" to the eye.
____ 6. Gently close the eye. Ask the student to keep the eye closed for a few minutes.
____ 7. Blot excess medication with a clean cotton ball or tissue for each eye treated.

Eye Ointment
____ 1. Gather necessary equipment: cotton balls and tissue.
____ 2. Cleanse the eye with a clean cotton ball wiping once from the inside to the outside. Use a clean cotton ball for each eye.
____ 3. Position student with head tilted back and eyes looking upward. Open the eye to expose the conjunctival sac.
____ 4. Approach the eye outside the field of vision. Avoid touching the tip to anything.
____ 5. Apply ointment in a thin layer along inside lower lid.
____ 6. Hold the lid open a few seconds.
____ 7. Gently close the eye. Ask the student to keep the eye closed for a few minutes.
____ 8. Blot excess medication with a new clean cotton ball or tissue, for each eye treated.

Ear Drops
____ 1. Gather necessary equipment: cotton balls and tissue
____ 2. Position the student.
a. If lying flat on a cot, turn face to the opposite side.
b. If sitting in chair, tilt head sideways until ear is horizontal.
____ 3. Cleanse entry to ear canal with a clean cotton ball as needed. Observe area.
____ 4. Straighten the ear canal. Pull outer ear gently down and back (ages 3 and under) or up and back (older children).
____ 5. Drop the medication on the side of the canal. Avoid the dropper touching anything.
____ 6. Instruct the student to maintain the position for 1 minute.
____ 7. Loosely place a cotton ball in the ear as ordered.

Inhaler: Monitoring Student Self-Administration
Follow individual student plan which may include self-management, self-administration and immediate availability with student carrying the medication. Observations when monitoring student self-administration of medication may include:
____ 1. Attach mouthpiece to inhaler which contains the medicine.
____ 2 Stand up, feet slightly apart.
____ 3. Shake inhaler for approximately two seconds.
____ 4. Position inhaler with canister upside down above mouthpiece.
____ 5. Holding mouthpiece 1-2 inches from lips (or as instructed), open mouth wide. When using a spacer, place mouth piece In mouthy
____ 6. Breathe out naturally
____ 7. Open mouth wide (or as instructed) and begin to inhale deep breath slowly. If using a spacer, seal mouth around mouthpiece and inhale a deep breath.
____ 8. After the beginning of deep breath, squeeze canister down on mouthpiece and breathe slowly as deeply as possible.
____ 9. Hold breath as long as possible - up to 10 seconds - to allow medication to settle as deeply as possible into and onto air passages.
____ 10. Wait approximately 1-2 minutes and repeat process. This technique should allow delivery of medicine into air passages opened by first whiff.

Auto-Injector Medication
In Allergic Emergencies follow individualized administration instructions which may include:
____ 1. Pull off safety cap.
____ 2 Place tip on thigh. May be injected through clothing.
____ 3. Press auto-injector against thigh until mechanism activates, and hold in place several seconds.
____ 4. Follow the school emergency procedure.

____ Total Score Possible 72 Score of 61 = 85% mastery

Comments:

SAMPLE Medication Administration

	Date	Skill	Verbalized	Demonstrated
A. Knows policy on medication. 1. All medications (prescription and over-the-counter) need a physician/dentist/parent signed request form before medications are given.
2. Medications are to be in prescription bottle or original container.
3. Medications are stored in locked drawer or cabinet.
4. Only designated and trained staff members or school nurses may give medications at school.
5. Medication administration records will be maintained on each student receiving, medications at school.
6. Medication folder contains the following: a. Parent and physician/dentist request forms.
b. District medication administration procedure.
c. Medication administration record.
d. List of trained staff able to administer medication (copy of skills sheet).
B. Procedure as forms and medications are received by staff. 1. Familiarize self with the medication that each student is taking.
2. Check possible side effects for each medication (list on form).
3. Check label on bottle (same as on form .
a. Name of student.
b. Dosage and time to give.
4. Transfer student's medication information on medication administration form.
5. Count the number of pills in bottle and record and date..
1. Wash hands.
2. Check medication record form for:
a. Child's name.
b. Name of medication.
c. Dosage unit and number of pills to give.
d. Time to give medication.
e. Check to see if pill has already been given.

3. Check label on medication to correspond to medication form (everything should match).
a. Child's name.
b. Name of medication.
c. Dose per pill and number of pills to give.
d. Time to give medication.
e. If information on record does not match medication container.
1. Call school nurse for instructions.
2. Parent may give medication until situation is resolved.
4. Place prescribed number of tablets or capsules in top of lid of prescription bottle or drop in paper cup. Don't touch medication with yourhands.
5. If medication is liquid, pour Into dispenser or cup provided by parents/doctor. Hold dispenser at eye level to assure correct dose.
6. Give student medication. Check label. a. Offer water.
b. Watch to see if he/she swallows medication without problems.
7. Place lid on medication bottle and place in locked cabinet or locked drawer out of reach and/or access to students. Check label.
8. Record medicine given on medication record in appropriate date space; sign and Initial.
9. A new parent/physician request form and newly labeled bottle is needed before any changes in medication can be administered at school. If changes are requested immediately, call RN.
10. Discontinuance of medication can be done any time by the parents, either verbally or in writing to the RN.
11. Any problems or concerns should be communicated to parents and/or school nurse.

__________________________________________________ ____________________________
Staff person/trainee Date

__________________________________________________ ____________________________
Name of trainer Date

Sample Medication Administration Plan

Name of student	Date of Birth
Grade	School

Name of licensed prescriber
Business telephone
Emergency telephone
Food/drug Allergies
Name of Medication:	Date Ordered:

Dosage
Route
Frequency
Specific Directions, e.g., times to be given:
Possible Side Effects, Adverse Reactions:
Quantity of Medication Received by School and Date:
Required Storage Conditions:
Delegated to (if applicable):
Plan for Field Trips:
Plans for teaching self administration, if applicable:
Parent/guardian name Home telephone Business telephone Emergency telephone

Diagnoses: (if not a violation of confidentiality)
Other persons to be notified of medication administration (with parental permission):
Other medications being taken by the student (if not in violation of confidentiality):
Location where medication administration will occur: Health Room Other (specify)
Plan for monitoring medication, if needed:

School Nurse Signature	Date
Parent/Guardian Signature	Date
Student's Signature, if appropriate	Date

(Medication order and parent/guardian authorization may be attached to this form.)

Back-up Plans (if delegates unavailable):
Duration of Order

Expiration Date of Medications Received

(For use in individual medication aides record only)

Name of Medication Aide________________________________________________

Date of Competency Assessment
Person Assessing Competency
Medication Aide Competency Assessment Documentation
Successful Completion Comments

Competency Standard #1
Competency Standard #2
Competency Standard #3
Competency Standard #4
Competency Standard #5
Competency Standard #6
Competency Standard #7
Competency Standard #8
Competency Standard #9
Competency Standard #10
Competency Standard #11
Competency Standard #12
Competency Standard #13
Competency Standard#14