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Free State Of Louisiana Medication Order Form

The State of Louisiana Medication Order form is a crucial document designed for licensed prescribers in Louisiana, Texas, Arkansas, or Mississippi to authorize medication administration for students. This form requires input from both a parent or legal guardian and a licensed prescriber, ensuring that necessary medical information is clearly communicated to school personnel. To ensure your child's health needs are met at school, please fill out the form by clicking the button below.

Open State Of Louisiana Medication Order Editor Here

Open State Of Louisiana Medication Order Editor Here

Structure

The State of Louisiana Medication Order form is a crucial document designed to ensure that students receive the necessary medications while at school, especially when those medications cannot be administered before or after school hours. This form is divided into three main parts, each serving a specific purpose. The first part requires the parent or legal guardian to provide essential information about the student, including their name, birthdate, school, and grade, as well as obtaining the guardian's signature. Following this, the licensed prescriber completes the second part, detailing the student's relevant diagnosis, general health status, and specific medication information, including dosage, frequency, and administration route. Additionally, this section addresses any potential side effects and contraindications, ensuring that the school staff is well-informed about the student’s health needs. The final part of the form focuses on students who may need to carry their own medications, such as asthma inhalers, allowing for self-administration under certain conditions. Each medication order must be documented on a separate form, and any changes to the medication regimen require new orders, ensuring that the information remains current and accurate for the safety of the student.

Sample - State Of Louisiana Medication Order 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): ___________________

	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

↓ State Of Louisiana Medication Order File

Form Characteristics

Fact Name	Details
Purpose	The State of Louisiana Medication Order form is designed for licensed prescribers to authorize the administration of medication to students during school hours.
Completion Requirements	The form must be completed by a licensed prescriber from Louisiana, Texas, Arkansas, or Mississippi. It requires input from a parent or legal guardian and includes sections for diagnosis, medication details, and health status.
Governing Law	This form is governed by Louisiana state law, particularly guidelines related to the administration of medication in schools as outlined in the Louisiana Revised Statutes.
Medication Administration	Medications administered at school are typically limited to those that cannot be given before or after school hours. Special circumstances require approval from the school nurse.

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