Conn. Agencies Regs. § 10-212a-6 - Documentation and record keeping

In addition to those records required for controlled drugs, the following shall apply:

(a) Each school or before- and after-school program and school readiness program where medications are administered shall maintain an individual medication administration record for each student who receives medication during school or program hours.

(1) Such record shall include:

(A) the name of the student;

(B) the name of the medication;

(C) the dosage of the medication;

(D) the route of administration;

(E) the frequency of administration;

(F) the name of the authorized prescriber;

(G) the dates for initiating and terminating the administration of the medication including extended year programs;

(H) the quantity received which shall be verified by the adult delivering the medication;

(I) any student allergies to food or medicine;

(J) the date and time of administration or omission including the reason for the omission;

(K) the dose or amount of drug administered;

(L) the full written or electronic legal signature of the nurse or qualified personnel for schools administering the medication; and

(M) for controlled medications, a medication count which should be conducted and documented at least once a week and co-signed by the assigned nurse and a witness.

(2) Transactions shall either be recorded in ink and shall not be altered or shall be recorded electronically in a record that can not be altered.

(3) The medication administration record shall be made available to the department for review until destroyed pursuant to the Section 11-8a and Section 10-212a(b) of the Connecticut General Statutes for controlled medications.

(A) The completed medication administration record for non-controlled medications, at the discretion of the school district, may be destroyed in accordance with Section M8 of the Connecticut Municipality Record Retention Schedule so long as it is superseded by a summary on the student health record;

(B) The completed medication administration record for controlled medications shall be maintained in the same manner as the non-controlled medications. In addition, a separate medication administration record needs to be maintained in the school for three years pursuant to Section 10-212a(b) of the Connecticut General Statutes.

(b) The written order of the authorized prescriber, the written authorization of the parent or guardian to administer the medication, and the written parental permission for the exchange of information by the prescriber and school nurse to ensure the safe administration of such medication shall be filed in the student's cumulative health record or, for before- and after-school programs and school readiness programs, in the child's program record.

(c) An authorized prescriber's verbal order, including a telephone order, for a change in any medication order can be received only by a school nurse. Any such verbal order shall be followed by a written order, which may be faxed, and shall be received not later than three (3) school days.

(d) Errors in the administration of medication

(1) The local board of education shall have a policy regarding notification and documentation of such errors. Such policy shall state:

(A) the manner in which persons are notified of errors in the administration of medication;

(B) any such error shall be reported immediately to the school nurse, the school nurse supervisor, the authorized prescriber, or, if none, the school medical advisor, and the parent or guardian; and

(C) the procedure to be followed in obtaining medical treatment when required as the result of such error.

(2) A report shall be completed using a medication error report form authorized by the board of education. The report shall include any corrective action taken.

(3) Any error in the administration of a medication shall be documented in the student's cumulative health record or, for before- and after-school programs and school readiness programs, in the child's program record.

(e) Reporting of the emergency administration of epinephrine.

Following the emergency administration of epinephrine by a qualified school employee to a student who does not have a prior written authorization of a parent or guardian or a prior written order of a qualified medical professional for the administration of epinephrine:

(1) Such administration shall be reported immediately to

(A) the school nurse or school medical advisor by the qualified school employee, and

(B) the student's parent or guardian by the school nurse or the qualified school employee, and

(2) a medication administration record shall be

(A) submitted to the school nurse by the qualified school employee at the earliest possible time, but not later than the next school day, and

(B) filed in or summarized on the student's cumulative health record according to any policy established by the local or regional board of education.

Notes

Conn. Agencies Regs. § 10-212a-6

Effective August 8, 1995; Amended October 7, 2010; Amended August 17, 2015