Guidelines for Medication Administration in Schools
Guideline #7: Policies and Procedures
7.1 Health Policies as Legal Responsibilities
It is the legal responsibility of school boards to put health policies in place. According to Minnesota Statutes § 121A.22, subd. 4, school board health procedures must be developed in consultation with health specialists. See additional information in Minnesota Med Administration in Schools Guideline 1.2.
7.2 Characteristics of Sound Policies
Local district policies and procedures on medication administration should be balanced, consistent, periodically updated according to school district directives for policy review, adaptable, based on the needs and ages of the student population at-large, consider community resources, and be aligned with professional practice.
Decisions made at the school district level will impact how students are ultimately served. The best policies are developed collaboratively, with the advice and assistance of the following: school board members, medical advisors, physicians, families, school staff (LSN/RN, UAPs, principal, etc.), local partners (pharmacists, public health workers, social workers, health care administrators), and other community members. These individuals might already be serving on a school health advisory committee. School staff, students, and parents all need to be aware of, understand, comply with, and aid in successful implementation of district policy and procedures. Parents should be advised annually of the district’s medication policy and procedures.
7.3 Contents of Policy and Procedures
A policy is a framework for operational decisions, which specifies a recommended course of direction consistent with the intent of the organization. It is an understanding by members of a group that make the actions of each person more predictable. Procedures are specific steps outlining how to implement policy, a way of telling how to perform activities or tasks (e.g., who does what and when).
District policies and procedures on medication administration should address the following: types of medications administered (see Glossary for definitions of prescribed, OTC, CAMs, emergency, investigational, and controlled substances); required information and authorization for initiating medication administration; desired medication administration outcomes; delegation of medication administration; training and supervision; procedures for medication administration; secure handling, storage, and disposal of medications; self-carrying of medications and self-administration; extended-day activities; emergency protocols; documentation and record keeping; and errors and omissions. District policy and procedures also need to address students’ individual health needs (short-term to long-term medication requirements), which might or might not involve a health/education plan.
7.4 Requests to Administer Medications in Schools
When medication administration in a school is requested by a parent/legal guardian, the policy will specify: (1) who will give the medications (LSNs/RNs, or in their temporary absence, delegation to paraprofessionals/UAPs, and in schools with no LSNs/RNs on staff, individuals trained and qualified to administer medication and assigned by school principals) and (2) whether and under what conditions self-medication by students is allowed.
No prescription medication may be administered without: (1) the written order of a licensed prescriber and (2) the written or oral authorization of the student’s parent/legal guardian. If the parent’s/legal guardian’s authorization is oral, then the oral authorization must be reduced to writing within two school days. Prescribed medication shall be administered to and taken by only the person for whom the prescription has been written. The district board and school personnel need to carefully consider the student safety ramifications for allowing OTC medication administration without a prescription. If a decision is made to administer OTC medication without orders from a licensed prescriber, directions should be taken from the official container’s label.
When queried, the State of Minnesota Office of the Attorney General concluded in a letter dated February 14, 2000, that, “school nurses do have the authority to provide over-the-counter medications to students upon a parent’s request, even without a physician’s order. It is important to note, however, that the school nurse has the ultimate authority and responsibility to reject a parent’s request and to decline to administer an over-the-counter medication [our emphasis] if the nurse believes that such medication is unnecessary, inappropriate, or could lead to patient harm. Further, school districts retain independent authority to implement policies that govern the administration of non-prescription drugs by school nurses. A school district, or an individual nurse, could choose to adopt a policy that requires a physician’s order before a school nurse administers a non–prescription medication to a student.” Contact Cheryl Smoot to access a copy of the Attorney General´s letter.
7.5 Medication Types
A number of different types of medications may be requested to be administered in schools: prescribed, OTC, CAMs, emergency, investigational, and/or controlled substances. These are not exclusive categories. For example, Ritalin™ is a prescription medicine and also a controlled substance, and ibuprofen is an OTC, but can also be a prescription medication. Responses to requests should be based on school district policies, the judgment of the LSN/RN, staff capabilities and training, and the school district administration’s level of support for established health policies.
Schools and school staff should not purchase or have a supply of any OTC medications or distribute them to students.
See definitions of types of medication in the Glossary.
7.6 Self-Carrying and Self-Administration of Prescription
An authorization form completed by the parent/guardian and physician and on file in the school will allow a student to responsibly carry medications for self–administration (see Minnesota Statutes §§ 121A.22, 121A.2205, 121A.221, and 121A.222. This authorization is renewed each school year. Documentation from the prescriber should include:
- records verifying that the student is capable of and has received training on administering the prescribed medication,
- the name and purpose of the medication,
- the prescribed dosage of the medication,
- the times at which or circumstances under which the medication may be given,
- the period for which the medication is prescribed,
- route of administration,
- potential side effects, and
- the duration of time the student can self-administer.
In the case of a disagreement regarding a student’s self–carrying and self–administration of medication, a meeting should be held among all those involved to sort out differences of opinion and develop a plan, keeping as a priority the student’s educational goals and health safety. If the meeting is unsuccessful and the situation is related to special education, a number of organizations can be drawn up for advice, such as PACER, Children’s Disability Law Center, or the Minnesota Department of Education’s No Child Left Behind Consolidated Programs or the Special Education, Compliance, and Assistance unit.
The LSN/RN, in consultation with the parent/legal guardian and physician, needs to evaluate the student’s health status and abilities for safe self-administration of prescription and non-prescription medications, observe the student’s first self–administration at school, and communicate regularly with the parent/legal guardian about any medication administration difficulties or successes. Two ways for an LSN/RN to assess student competence are to have the student come to the health office to self–administer, where the LSN/RN can periodically observe the procedure, or by written documentation from a licensed prescriber stating that the student is administering appropriately. A student self–administering medications may document it on a personal daily medication form.
When the request for self–carrying includes controlled substances, the individual request and privilege needs to be examined and a plan made for keeping the student as independent as possible (e.g., medications could be self-administered, but stored in the health office).
When students are self-carrying and self-administering medications, the student teaching team and other appropriate staff can be informed on a need–to–know basis for legitimate educational interests, as specified by FERPA. The student and his or her parent/legal guardian are to be informed of how and to whom this information is shared. If there are difficulties with the student’s ability to safely self–administer, including medication security issues, the building administrator discusses with the student and parent/legal guardian the possible discontinuance of the student’s self–administration. This privilege can also be discontinued if medications are shared with other students or not taken as authorized by parents/legal guardians.
In school districts without LSNs/RNs on staff, educational administrators under the direction of school boards are responsible to set up a system through which: policies are developed in consultation with LSNs/RNs, people are assigned and trained to do health services, the procedures are done safely and consistently, and all necessary documentation is completed. They are also responsible to find appropriate resources and medical expertise to address their students’ medication administration needs. School administrators cannot legally fulfill the role of RNs.
Those districts with LSNs/RNs on staff or on contract will be able to call on staff to take the lead on these responsibilities.
According to the Minnesota Nurse Practice Act, the LSN/RN has the authority and responsibility to reject a request if the LSN/RN believes the request is unnecessary, inappropriate, or could lead to harm.
For further information on the duties of students, see Minnesota Guideline 2.5.
7.7 Self-Carrying and Self-Administration of Non-Prescription
According to Minnesota Statute 121A.222 (2005), a secondary student may possess and use non–prescription pain relief in a manner consistent with the labeling if the district has written parental or guardian authorization.
The FDA states there are two categories of over–the–counter pain reliever/fever reducers: acetaminophen and nonsteroidal anti-inflammatory drugs (NSAID). “Acetaminophen is used to relieve headaches, muscle aches and fever. It is also found in many other medicines, such as cough syrup and cold and sinus medicines. OTC NSAIDs are used to help relieve pain and reduce fever. NSAIDs include aspirin, naproxen, ketoprofen and ibuprofen, and are also found in many medicines taken for colds, sinus pressure and allergies.” It is important that students are not taking medications with aspirin as research has established a link between Reyes Syndrome and the use of aspirin and other salicylate containing medications.
If a student happens to take medications that contain the same active ingredients, they might be taking two times the normal dose and not realize it. To avoid multiple dosing, it would be best practice if the school health staff (e.g., school nurse) knew and could provide education and guidance related to student’s self administration of OTC medications. In addition, a student self-administration agreement should be in place.
School districts can offer the following two options:
First, as was required for prescription medications, an authorization form completed by the parent/legal guardian and physician and on file in the school or a temporary oral authorization will allow a student to responsibly carry non-prescription medications for self-administration. No request for self-carrying or self-administration will be honored if dosage exceeds the recommendations on the manufacturer’s label. Physician authorization is especially important when there is no LSN/RN available to the school district.
A second option for schools is to have written parental/legal guardian authorization, a student contract, and LSN’s/RN’s assessment. If the LSN/RN assesses that it is appropriate, a request would be made for a physician’s order. If the student is allowed by school policy to carry medication, the LSN/RN performs an assessment and works with the parent/legal guardian and student to draw up a written contract. This privilege can be discontinued if medications are shared with other students or not taken as authorized by parents/legal guardians.
In school districts without LSNs/RNs on staff, educational administrators under the direction of school boards are responsible to set up a system through which: policies are developed in consultation with LSNs/RNs, people are assigned and trained to do health services, the procedures are done safely and consistently, and all necessary documentation is completed. They are also responsible to find appropriate resources and medical expertise to address their students’ medication administration needs. School administrators cannot legally fulfill the role of LSNs/RNs.
Those districts with RNs on staff or on contract will be able to call on staff to take the lead on these responsibilities.
For further information on the duties of students, see Minnesota Guideline 2.5.
7.8 Handling, Storage, and Disposal of Medications
Although ideally parents/legal guardians deliver their students’ medications to the LSN/RN assigned to the school, this is most often done by students. The LSN/RN should be notified in advance when students will be bringing medication. This is the first step in student accountability for medication administration.
It should be made clear in advance where emergency medications such as rescue inhalers, Diastat™, Epi-pen™, and Glucagon™ are stored and who is responsible for supplying or administering them. District policy or procedures should specify that emergency medications should be accessible to staff or students who might need them, but be inaccessible to others.
The LSN/RN must examine on-site any new medication, medication order, and permission form and assess the appropriateness of delegating medication administration to any other school personnel.
All medications should be stored in a locked drawer or cabinet used exclusively for medications and kept no longer than the medication expiration date or end of the school year, whichever is sooner. Cabinets should not contain glass doors and should be anchored securely to a solid surface. Access to stored medication and medication cabinet keys must be limited to school personnel authorized to administer medications. Medication requiring refrigeration should be stored in a locked refrigerator or in a locked container in the refrigerator specifically for medications. Medications should not be stored in individual classrooms unless all of the above standards can be met and the individuals responsible for administration have been properly trained. Each medication should be stored in the original pharmacy- or manufacturer-labeled container with the student’s name on it.
Expiration dates should be checked, medications disposed of upon expiration, and parents notified. All unused, discontinued, or outdated medications shall be returned to the parent/legal guardian and the return appropriately documented. With parent/legal guardian consent, such medications may be destroyed by the school when two individuals are present to witness and document the disposal.
Needles and syringes should be disposed of in a manner consistent with the following guidelines (see OSHA Blood-borne Pathogen Standard 29 of C.F.R. 1930.1030 and Minnesota Rules, chapter 5206):
- Needles should not be recapped and should not be purposely bent or broken.
- Disposable syringes and needles (and other sharp items) should be placed in approved sharps containers and labeled “biohazard.”
- Custodial staff or other agents must be given directions for disposing of containers according to established procedures for regulated medical waste.
7.9 Planning and Standardized Forms
The school district should establish standardized record-keeping forms that are uniform and consistent across the district and make them available in a variety of ways (e.g., district web site and handbook).
Medication management plans include overall district plans and individual student plans, which give contingency directions for when the LSN/RN or designee is not available. Plans need to be flexible for the number of staff who interact with the students on medication regimes in school. Parents and appropriate school staff all give input into the medication administration plan for individual students. See the glossary for more information about the types of student plans.
7.10 Record Keeping
School health personnel should maintain accurate written or electronic records specific to each student receiving medications, including parental consent forms, authorization from licensed prescribers, individual documentation, and emergency procedures.
A picture of the student attached to the medication log or the medication authorization form can help ensure that the proper student gets the proper medication. Documentation must contain student name and identification number; room; name of medication; dosage; route; date and time given; beginning and end dates; any special circumstances related to the procedures; the student’s unusual reactions or responses; omissions, absences, or refusals; name of the individuals giving the medication; count of controlled substances, and medication disposal. Documentation must be done in unalterable ink (no erasing, no white out) and should include significant reactions. These are legal documents and provide protection to those who administer medications in schools.
Health room documents/logs should be retained by the school district for six years after student graduation or leaving the district (State of Minnesota School District General Record Retention Schedule, 2000). Health and immunization information should be retained for at least five years after the student attains the age of majority (18), so until the age of 23 (Minnesota Statutes § 121A.15, subd. 7). More information about a district's retention policy is available from your local school district.
A summary of individual student medication records should be transcribed (e.g., 9/15/00 – 5/1/01 – Ritalin™ 20 mg. at lunch time) to a student’s cumulative health record. Logs should not be destroyed if summary information has not been transferred to the cumulative health record. Student privacy must be protected as outlined in A&D, FERPA, HIPAA, IDEA, Minnesota Government Data Practices (chapter 13), MMHA, and MMRA.
School health records should be kept in a central location with a locked system to assure record security. All files should be locked at the end of each day. Policy and procedures must define who has responsibility for maintaining files, entrance and exit of records, tracking, security, and when files are pulled and sent to another school.
7.11 Procedures for Emergency Medications
Students with known chronic health conditions sometimes need emergency medications to prevent or treat anaphylaxis, respiratory distress, diabetic hypoglycemia, seizures, cardiac incidents, and social/emotional crises. In an emergency, if two or more people are available, one can administer the emergency medication while the other calls 911. If only one person is available, that person should first administer the medication and then call 911.
Some students will have individual emergency care plans and parental and physician’s authorization forms and instructions that need to be accessed and adhered to.
See Minnesota Guideline 3.3 for further information on preparing for emergencies.
7.12 Investigational Drugs
The National Association of School Nurses recommends that a parent’s/legal guardian’s request to have investigational drugs administered at school should be evaluated on a case-by-case basis with the parent/legal guardian, the prescribing physician or provider, and the school nurse. It must be done in accordance with state laws regarding investigational drugs.
7.13 Complementary and Alternative Medicines (CAMs)
No substance should be administered to any child or adolescent without the express written request of the parent or guardian. Schools should exercise caution about CAMs administration in school, and the LSN/RN should assess the necessity of administering CAMs in school. Such products should be provided by the parent (as with all medications administered at school) and in an original container with proper labeling (name of student, date, name of medication, dose, time of administration, prescriber as appropriate, and expiration date) and manufacturer’s indications and contraindications.
CAMs can frequently interact with other prescribed and non-prescribed medications, enhancing or inhibiting effects, so parents/legal guardians should seek guidance from their licensed prescribers about drug interactions.