Medication Administration Record
Professional Medication Administration Record template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Medication Administration Record
TEMPLATE • Inspection-Ready AFH Standard
1. Resident & Prescriber Identification Header
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Routine Medication Grid (31-Day Tracking)
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. PRN (As-Needed) Medication Log
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Resident & Prescriber Identification Header
Resident name, DOB, allergies, primary physician, and pharmacy phone number.
Routine Medication Grid (31-Day Tracking)
Medication name, dosage, route, frequency, time slots, and caregiver initials matrix.
PRN (As-Needed) Medication Log
Date, time, PRN reason, dosage given, caregiver signature, and 1-hour result evaluation.
Caregiver Initial Identification Key
Full printed name, signature, and initials for every staff member administering meds.
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