9.4.2.6: Contents of Medication Record

The file for each child should include a medication record maintained on an ongoing basis by designated staff for all prescription and non-prescription (over-the-counter [OTC]) medications. State requirements should be checked and followed. The medication record for prescription and non-prescription medications should include the following:

1. A separate consent signed by the parent/guardian for each medication the caregiver/teacher has permission to administer to the child; each consent should include the child’s name, medication, time, dose, how to give the medication, and start and end dates when it should be given;
2. Authorization from the prescribing health professional for each prescription and non-prescription medication; this authorization should also include potential side effects and other warnings about the medication (exception: non-prescription sunscreen and insect repellent always require parental/guardian consent but do not require instructions from each child’s individual medical provider);
3. Administration log which includes the child’s name, the medication that was given, the dose, the route of administration, the time and date, and the signature or initials of the person administering the medication. For medications given “as needed,” record the reason the medication was given. Space should be available for notations of any side-effects noted after the medication was given or if the dose was not retained because of the child vomiting or spitting out the medication. Documentation should also be made of attempts to give medications that were refused by the child;
4. Information about prescription medication brought to the facility by the parents/guardians in the original, labeled container with a label that includes the child’s name, date filled, prescribing clinician’s name, pharmacy name and phone number, dosage/instructions, and relevant warnings. Potential side effects and other warnings about the medication should be listed on the authorization form;
5. Non prescription medications should be brought to the facility in the original container, labeled with the child’s complete name and administered according to the authorization completed by the person with prescriptive authority;
6. For medications that are to be given or available to be given for the entire year, a Care Plan should also be in place (for instance, inhalers for asthma or epinephrine for possible allergy);
7. Side effects.

RATIONALE

Before assuming responsibility for administration of prescription or non-prescription medicine, facilities must have written confirmation of orders from the prescribing health professional that includes clear, accurate instructions and medical confirmation of the child’s need for medication while in the facility. Caregivers/teachers should not administer medication based solely on a parent’s/guardian’s request. Proper labeling of medications is crucial for safety (1). Both the child’s name and the name and dose of the medication should be clear. Medications should never be removed from their original container. All containers should have child resistant packaging. Potential side-effects are usually included on prescription and OTC medications if the packaging is left intact (2).

Medications may have side-effects, and parents/guardians might not be aware that their child is experiencing those symptoms unless they are recorded and reported. Serious medication side-effects might require emergency care. Adjustments or additional medications might help those symptoms if the prescribing health professional is made aware of them. Children who do not tolerate medications may vomit or spit up the medication. Notation should be made if any of the medication was retained in those cases. Children may also vigorously refuse medications, and plans to deal with this should be made (1,2).

The Medication Log is a legal document and should be kept in the child’s file for as long as required by state licensing requires.

COMMENTS

A curriculum for child care providers on safe administration of medications in child care is available from the American Academy of Pediatrics at: http://www.healthychildcare.org/HealthyFutures.html.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
9.2.3.9 Written Policy on Use of Medications
9.4.2.1 Contents of Child’s Records
Appendix AA: Medication Administration Packet

REFERENCES

1. Healthy Child Care America. 2010. Healthy futures: Medication administration in early education and child care settings. American Academy of Pediatrics. http://www.healthychildcare.org/HealthyFutures.html.
2. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.