MDS Client Medication Form

Instructions for Staff:

1. Medication Received:

Record all medication received, including the quantity and signatures of both parties.

2. Medication Administration:

Follow the prescribed dosage, route, and schedule.
Check the client’s medication chart for accuracy before administering.

3. Emergency Protocols:

If an incident occurs, follow the steps outlined in Section 4.

4. Documentation:

Ensure all fields in Sections 1, 2, and 3 are accurately completed.

Client Name*

First NameLast Name

Date of Birth*

Date

Date*

Date

Section 1: Medication Received by Disability Support Worker *

	Date Received	Medication Name	Dosage (mg/ml)	Quantity received	Received From (Name)	Received by (DSW Name)
Details
Details
Details

Section 2: Medication Administration Details*

	Medication Name	Dosage (mg/ml)	How does the client take it?	Time to administer	Purpose/Condition	Prescribing Doctor
Details
Details
Details
Details

Section 3: Medication Administered Record (completed when DSW has given medication)*

	Time Given	Dosage (mg/ml)	Administered by Name	Witness Name	Notes (eg: side effects of observation)
Date
Date
Date
Date

Section 4: Emergency Protocols

If any adverse reactions, errors, or incidents occur during medication administration:

1. Immediately contact emergency services (000) if required.
2. Notify the on call 0497 173 572 straight away.
3. Record the details in the “Notes” section above.
4. Advise carer upon handover.

Section 5: Consent Acknowledgment

I, First Name* Last Name* [Participant/Guardian], give consent for the Disability Support Workers of Mildura Disability Support to assist with the administration and management of First Name* Last Name* (client's name) medication as outlined in this form.

First Name* Last Name* Signature* Date*

Section 6: Medication Storage Declaration

I confirm that all medication has been securely stored in compliance with NDIS Practice Standards, ensuring safety and preventing unauthorised access.

First Name Last Name Signature Date

Staff Member Declaration

I confirm that I have received, stored, and/or administered the medication as prescribed and in accordance with company policies.

First Name* Last Name* Signature* Date*