Documentation and Record-keeping

(A) Each school where medications are administered by school personnel shall maintain a medication administration record for each student who receives medication during school hours. (1) Such record at a minimum shall include a daily log and a medication administration plan, including the medication order and caregiver authorization. The medication administration plan shall include the information as described in 105 CMR 210.005(E). (3) The daily log shall contain: (a) the dose or amount of medication administered; (b) the date and time of administration or omission of administration, including the reason for omission and action taken post omission; (c) a mechanism for identifying the person administering each dose. (4) The school nurse shall document in the medication administration record significant observations of the medication's effectiveness, as appropriate, and any adverse reactions or other harmful effects, as well as any action taken. (5) All documentation shall be recorded in a manner that prevents alteration or destruction of the record. (6) With the consent of the caregiver, or student where appropriate, the completed medication administration record and records pertinent to self-administration shall be filed in the student's cumulative health record. When the caregiver or student, where appropriate, objects, these records shall be regarded as confidential medical notes and shall be kept confidential, except as provided in 105 CMR 210.000. (B) Medication errors, as defined in 105 CMR 210.005(F)(5), shall be documented by the school nurse on the school/district's accident/incident report form and in the student's health record. These reports shall be retained in a location as determined by school policy and made available to the Department of Public Health upon request. All suspected diversion or tampering of drugs shall be reported to the Department of Public Health, Drug Control Program. All medication errors requiring medical care or ongoing assessment shall be reported as instructed to the Department of Public Health. (C) The school district shall comply with the Department of Public Health's reporting requirements for medication administration in the schools. (D) The Department of Public Health may inspect any individual student medication record or record relating to the administration or storage of medications without prior notice to ensure compliance with 105 CMR 210.000.