Name of Child: Date of Birth: Month & Year: Home Address: Hospital NHS Number: Name & No: Telephone Number: Date Placement began: Date Placement ended: Next of Kin Contact Details: Name/s, Address and Telephone Number of Carer/s: Address and Telephone Number: Child’s G.P’s Name, Name, Location, and Telephone Number: Child’s Hospital Consultant’s Name, Address and Telephone Number: Child’s Dentist’s Name, Address and Telephone Number: Child’s Social Worker’s Medication Sensitivities/Allergies: Details of disability, invasive procedures and significant other treatments: Special dietary requirements: Immediately after administration of medication, carers should print date, time and initials in the appropriate boxes. If medication cannot be given as prescribed, omitted or for refused and give the reasons on the please indicate with ‘O’ for ‘R’ back page. In the event of an emergency, this record should be taken with the child to hospital. All information on this record should be treated as confidential. REASONS FOR MEDICATION ADMINISTRATION GIVING DATE DOSE AND RECOMMENDED AND ROUTE (e.g.Oral, MEDICATION (e.g. FREQUENCY TIME TO BE GIVEN STRENGTH gastronomy) epilepsy) SPECIAL INFORMATION TIME GIVEN
Name of Child: Home Address: Telephone Number: Date of Birth: Month & Year: Hospital Name & No: NHS Number: Date Placement began: Date Placement ended: Next of Kin Contact Details: Name/s, Address and Telephone Number of Carer/s: Child’s G.P’s Name, Address and Telephone Number: Child’s Hospital Consultant’s Name, Location, and Telephone Number: Child’s Dentist’s Name, Address and Telephone Number: Child’s Social Worker’s Name, Address and Telephone Number: Medication Sensitivities/Allergies: Details of disability, invasive procedures and significant other treatments: Special dietary requirements: Immediately after administration of medication, carers should print date, time and initials in the appropriate boxes. If medication cannot be given as prescribed, please indicate with ‘O’ for omitted or ‘R’ for refused and give the reasons on the back page. In the event of an emergency, this record should be taken with the child to hospital. All information on this record should be treated as confidential. MEDICATION AND STRENGTH DOSE AND FREQUENCY ADMINISTRATION ROUTE (e.g.Oral, gastronomy) REASONS FOR GIVING MEDICATION (e.g. epilepsy) SPECIAL INFORMATION RECOMMENDED TIME TO BE GIVEN DATE TIME GIVEN
family-placement-medicine-administration-record-form-february-2017.docx