Medication Order

Date

MonthDayYear
Date
Participant's Name

First NameLast Name
OCHN CON ID #
DOB
Allergies and Action to be taken
Current Medications, Dosage, Frequency, and Side Effects
Headache

Tylonel- 2 tabs every 4 hours PRNAspirin- 2 tabs every 4 hours PRNEquivalent
Diarrhea

Kaopectate- 2-3 Watery stools within 4 hour period-give per instructions on bottleEquivalent
Fever

Tylonel-Take temperature every 4 hours and encourage fluids. Take 2 tabs every 4 hours PRN for temperature aove 100 degrees.Equivalent
Menstrual Cramps (If Applicable)

Tylenol-Take as needed and directed on the bottle. Not to exceed 3 daysAspirinEquivalent
Minor Abrasions and Cuts

Neosporin BID- Clean with soap and water and apply iontmentEquivalent
Allergies

Benadryl- Seasonal or allergic reactionEquivalent
Diaper Rash

Desitin- PRN every diaper chnage while rash is presentEquivalent
Sunscreen

Chapstick- For dry lipsVaseline- For dry skinhSunscreen- Protect against suburn during outdoor activities
Itching/Skin Sensitivity-Topical Anti Itch Cream

Benedryl CreamEquivalent
*Above meds will be dispensed by New Gateways, Inc. representative when needed

*** Guardian can sign the form if New Gateways Medical Coordinator does not administer prescribed medication to said participant**.
Signature of Guardian or Home Manager

Clear
Date

MonthDayYear
Date
Should be Empty: