LDSS-7004. Log of Medication Administration

Form LDSS-7004, Log of Medication Administration is a form used by the New York State Office of Children and Family Services to document the administration of medication to children in their care. It is used by staff in residential facilities, daycare, and community-based programs.

The form consists of several sections. The first section contains general information about the child, including name, date of birth, and address. The second section is for the staff administering the medication and contains fields for name, title, signature, date of administration, and any notes regarding the medication. The third section is for the physician or prescriber and includes fields for name, signature, date of prescription, and any notes regarding the medication. The fourth section is for the parent or guardian and contains fields for name, signature, date of consent, and any additional notes.

Important fields in this form include the name and date of birth of the child, the name of the staff administering the medication, the name and signature of the physician or prescriber, and the name and signature of the parent or guardian. It is important to accurately fill out each section of the form, as it is used to ensure that medication is administered safely and according to the prescriber's instructions. Any discrepancies or errors should be corrected by the staff administering the medication.

An example situation where this form would be used is in a residential facility for children in foster care. The staff administering the medication would fill out the form for each child whenever medication is given, and the physician or prescriber and parent or guardian would sign to authorize the administration of the medication. The benefits of using this form are that it provides documentation of the administration of medication and ensures that it is done safely and according to the prescriber's instructions.

Specific instructions for filling out the form include ensuring that all sections are completed accurately and that all signatures are present. Related forms include the LDSS-7005, Physician Authorization for Medication Administration, and the LDSS-7006, Consent for Medication Administration. Additional documents that may be required include the prescription from the physician or prescriber and any consent forms from the parent or guardian.