Medications in School
School Health Assistant (SHA) Orientation
Conducted by Department of Education
Refer to SHA Manual Section 4
Revised 8/2024
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Medications Objectives
Revised 8/2024
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Medication Management in School �(SHA 4-1)
Purpose: To guide medication administration by the School Health Assistant, subject to Hawaii Revised Statutes HRS §302A-853, and to ensure safe and appropriate administration of medication in the public school setting.
Note: SHAs are NOT licensed health care providers and are NOT trained or allowed by State law to perform assessments necessary to determine the need for medication.
Revised 8/2024
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Medication Management in School �(SHA 4-1 Cont’d)
Policy: Administration of medication may be provided by the Hawaii Department of Education (Department) School Health Assistant (SHA) or Substitute-SHA during regular school hours subject to:
a. Written request and consent from a parent/legal guardian;
b. A medication order from a licensed physician (as
defined by HRS §334-1), or other practitioner with prescriptive
authority; and
c. Documented approval by the Department authorized health care
professional, including a Department Nurse (DOE RN), or Hawaii
State Department of Health (DOH) Public Health Nurse (PHN),
who has recommended that the medication is necessary for
student’s attendance at school.
Revised 8/2024
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Medications in School�(SHA 4-2A-1 #9)
Revised 8/2024
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�Medications in School �Initiating a Request for Medication Services �(SHA 4-1) �
Revised 8/2024
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1. Initiating a Request of Medication Services
A. The parent(s)/legal guardian(s) initiates any request for
medication services in school. This may include a request for
storage and administration of medication by the school, or
requests for a student to self-carry and self-administer
medication at school.
1. For requests related to diabetes care, such as insulin or
glucagon, refer to Diabetes Management in School (5-5).
Medications in School �Initiating a Request for Medication Services �(SHA 4-1 Cont’d)
2. For requests to allow a student to self-carry/administer
medication, refer to Self-Administration of Medication (4-3).
3. For all other requests to store or administer medications, the
SHA shall be familiar with the Request to Store and
Administer Medications (SH36) form, and:
a. Provide the parent(s) or legal guardian(s) with all 4 pages
of the SH36 form.
b. Orient the parent(s)/legal guardian(s) to the SH36 form
and review all points of page 2 “Notice To Parents/Legal
Guardians And Healthcare Providers” (4-2A-1).
4. Notify administration any time a parent(s)/legal guardian(s) is
provided with the SH36 form to ensure school compliance
with Child Find obligation.
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Medications in School �Initiating a Request for Medication Services �(SHA 4-1 and 4-1-1 Cont’d)
5. The SHA shall be aware of the following situations
and consult with school administration:
a. If a student is in foster care, the Child
Welfare Services (CWS) case worker needs
to sign health related documents. Foster
parents cannot sign health related
documents.
b. If the student is at the age of majority (16 years
of age or older) of otherwise legally
emancipated, the student needs to sign
documents as their own legal guardian.
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Medications in School �Receiving a Request to Store & Administer Meds (SH36)�(SHA 4-1-1)
II. Receiving a Request to Store and Administer
Medications (SH36 Form)
A. The school should ensure that all SH36 forms
received at the school from any source are
transmitted to the school SHA or responsible health
room designee.
B. Prior to implementation, medication request forms
must meet the requirements and procedures
described within the section titled, “Notice to
Parents/Legal Guardians and Healthcare Providers.”
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Medications in School �Receiving a Request to Store & Administer Meds (SH36)�(SHA 4-1-1 Cont’d)
C. The SHA or responsible health room designee shall first screen
the received SH36 form for the following requirements:
1. All medication request forms must indicate on page one (1):
a. “Student Name (Last, First)” with the first and last name
that matches the school record.
b. “Date of Birth” that matches the student’s date of birth in
the school record; and,
c. At least one “Parent/Legal Guardian Name” and at least
one contact phone number is provided.
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Medications in School �Receiving a Request to Store & Administer Meds (SH36)�(SHA 4-1-1 Cont’d)
2. Section I. “Parents/Legal Guardian’s Request,
Authorization, and Waiver of Liability” must be completed,
including:
a. All “initial” spaces have parent/legal guardian initials
applied;
b. “Parent/Legal Guardian Signature” is completed;
c. “Parent/Legal Guardian Printed Name” is completed and
matches a contact person indicated at the top of the page;
and,
d. “Date” of parent/legal guardian signature is completed.
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Medications in School �Receiving a Request to Store & Administer Meds (SH36) �(SHA 4-1-1 Cont’d)
3. At least one (1) or both Section II(a) and II(b)
“Physician’s or Practitioner with Prescriptive
Authority’s Requested Orders” must be
completed, including:
a. Top of page (i.e. page 3 for section II(a) orders,
and page 4 for II(b) orders) indicates the
“Student’s Name” and “Date of Birth” which
match the respective student name and date of
birth indicated on page one (1).
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Medications in School �Receiving a Request to Store & Administer Meds (SH36)�(SHA 4-1-1 Cont’d)
b. For the purposes of screening Section II(a) and
II(b), there must be the presence of
“Physician/Practitioner” box:
(1) Includes the provider “Name” which is
legible
(2) Provider “Signature” and “Date” are
completed
(3) At least one contact method is provided (i.e.
“Phone” or “Fax” number, or “Address”)
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Medications in School �Nursing Consultation & Recommendations of Med Admin�(SHA 4-1-1 Cont’d)
4. Any SH36 form received without meeting the
requirements above (paragraph C.1-3) shall be
returned to the parent(s)/legal guardian(s) to be
completed. SH36 forms that meet these
requirements may be considered appropriate for
referral to a consulting nurse as noted below.
III. Nursing Consultation and Recommendations for Medication Administration
A. The SHA shall transmit to the PHN any SH36 forms
that have met screening requirements noted above
as soon as possible.
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Medications in School �Nursing Consultation & Recommendations for Med Admin�(SHA 4-1-1 and 4-1-2 Cont’d)
1. Fax/send the SH36 to the assigned PHN.
2. If this is a new request, ensure the PHN10R
(5-1A) is also submitted.
B. If the school or SHA receives parent/legal guardian
signed documents necessary for DOH (PHN 28s and
NPP), the forms shall be routed to the responsible
PHN.
C. The SHA will receive the PHN consultation report/
written recommendation, along with the Emergency
Action Plan (EAP), if applicable.
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Request for Nursing Services �PHN-10R
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Notice of Privacy Practices (NPP), Page 1
Revised 8/2024
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Practices (NPP) and
b. the two (2) Protected
Health Information (PHI)
prior to parent’s/legal
guardian’s
acknowledgement and
signature.
Notice of Privacy Practices (NPP), Page 2
Revised 8/2024
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Authorization for Use or Disclosure of Protected Health Information PHI (PHN 28) – PHN with School
Revised 8/2024
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SHA will also provide to parent(s)/legal guardian(s) along with the SH36, Revised 2021:
Two (2) copies of PHN 28, the “Authorization for Use or Disclosure of Protected Health Information (PHI)” to be completed and reviewed with parent(s)/legal guardian(s).
One PHI (PHN 28) is for the PHN to communicate and share PHN consultation report/written recommendation with the school.
Authorization for Use or Disclosure of Protected Health Information PHI (PHN 28) – PHN with MD
Revised 8/2024
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The other PHI (PHN 28), if necessary, is for PHN to communicate with the PMD.
PHN Consultation Report ��
Revised 8/2024
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Procedure when SH36 Request Received by SHA�(SHA 4-1)
1. The SHA shall keep the PHN consultation report/written
recommendation and the SH36 in their medication binder in the
health room.
2. The SHA shall notify Administration and, if requested, provide
copies of PHN consultation report/written recommendation and
the SH36.
3. If the student’s photograph is available, place it with the SH36
and/or the EAP to confirm the student’s identity.
Revised 8/2024
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Medications in School �Implementation of Completed Request to Store & Administer Meds �(SHA 4-1-2 Cont’d)
IV. Implementation of a Completed Request to Store
and Administer Medications (SH36) Form
A. Accepting Medication into the Health Room
1. NO medications shall be accepted or administered
by DOE staff without a completed PHN
consultation report/written recommendation and a
completed SH36, including SH36 Section III with
documented approval by the PHN.
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Medications in School �Implementation of Completed Request to Store & Administer Meds �(SHA 4-1-2 Cont’d)
2. IMPORTANT: Accept the medication only when it is
in a pharmacy labeled container, provided by the
parent(s)/legal guardian(s).
3. Medication label must state: the name of the
student, the name of the medication, the dosage,
the time to be given, and the name of the medical
provider.
4. Log medication received on the back of the
Monthly Medication Record Sheet (4-4A-1) and
have parent/legal guardian print and sign.
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Medication in Schools �Implementation of Completed Request to Store and Administer Meds �(SHA 4-1-2 Cont’d)
B. Storage of Medication in the Health Room
1. Medication shall be kept in a locked cabinet, drawer, or
refrigerator.
2. Absolutely no food or drinks are allowed in a refrigerator
with stored medications.
a. Food and/or drinks for the students with diabetes or other
health conditions are kept in a refrigerator designated for food
or drinks.
b. Refrigerators designated for “medication only” and “for food
or drinks” should be labeled as such.
Revised 8/2024
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Communication with Other DOE Staff �(SHA 4-1-1)
C. Communication with other DOE Staff
1. Notify the teacher or other involved school personnel that the
student is to receive medication in the health room by sending
the Memo to Teacher (SH36T – SHA4-8A).
Revised 8/2024
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Medications in School �Implementation of Completed Request to Store & Administer Meds�(SHA 4-1-2 Cont’d)
D. Change in the Medication Orders
1. Issue a new SH36 if there is any change in the medication
dosage or time as a medical provider’s order is required.
a. Confirm that any current SH36 medication administration
shall continue, or for discontinuation pending a new SH36,
follow Discontinuation of Medication Orders (paragraph E).
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2. The parent(s)/legal guardian(s) is responsible for obtaining a
new SH36.
3. Medications will be in a new container/vial appropriately
labeled to reflect the new order(s).
4. Do not accept a new medication until the PHN has
completed an updated PHN consultation
report/written recommendation.
Medications in School �Implementation of Complete Request to Store & Administer Meds�(SHA 4-1-3)
E. Discontinuation of Medication Orders
1. When the SHA receives a notification from the parent(s)/legal
guardian(s) to discontinue a medication, the SHA will:
a. Discontinue giving the medication to the student.
b. Instruct parent(s)/legal guardian(s) to obtain written
documentation from the medical provider regarding the
discontinuation of medication and to pick up any leftover
medication from the health room.
c. Inform the PHN who will follow up with medical provider or
parent(s)/legal guardian(s) as needed.
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Medications in School �Implementation of Completed Request to Store & Administer Meds �(SHA 4-1-3 Cont’d)
d. Document all communication with the parent(s)/legal guardian(s),
PHN, etc.
(1) Document the communication with the parent(s)/legal
guardian(s) in Infinite Campus Health Module Contact Log.
(2) Complete the discontinuation procedure for the
Monthly Medication Record Sheet (4-4A), as
described in 4-4-1, item D, “Discontinuation Of
Medication Administration.” Log med received/
returned on back of Monthly Med Record Sheet (4-4A-1).
F. Renew the SH36 every school year.
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Medications in School �Daily, Routine, Scheduled Medication Administration �(SHA 4-1-3 Cont’d)
V. Daily, Routine, Schedule Medication Administration
A. Medication Supply Maintenance
1. Count the number of pills when the medication
counter is received and at the beginning of each
day. Record on the Monthly Medication Record
Sheet (SH36AM) in the “Daily Starting Pill Count”
column.
2. SHA is responsible to call the parent(s)/legal
guardian(s) if a medication supply is not received
in a timely manner.
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Medications in School �Daily, Routine, Scheduled Medication Administration �(SHA 4-1-3 Cont’d)
a. Document all communication with the parent(s)/legal
guardian(s) on the back of the Monthly Medication Record
Sheet (SH36AM) under “Additional Comments.”
3. Send home the empty medication container.
4. If there are any leftover medications, the SHA shall notify the
parent(s)/legal guardian(s) for pick up by the end of the school
year. If there is no reply after attempts, notify Administration of
the leftover medications.
5. Log medication returned on the back of the Monthly Medication
Record Sheet (4-4A-1) and have parent/legal guardian print and
sign.
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Medications in School �Daily, Routine, Scheduled Medication Administration �(SHA 4-1-3 Cont’d)
6. If a parent(s)/legal guardian(s) administers
medication to the student, document this in detail
on the back of the Monthly Medication Record
Sheet (SHA36AM) under “Additional Comments”
and mark the administration time using the
code, “P.” (Parent)
B. Administration of Daily, Routine, Scheduled Meds
1. Add the student and medication info to the Daily
Medication List (SH36B).
2. Create the student’s Monthly Medication Record
Sheet (SH36AM).
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Medications in School �Daily, Routine, Scheduled Medication Administration �(SHA 4-1-3 and 4-1-4 Cont’d)
3. As changes occur, update the Daily Medication
List (SH36B) and create a new Monthly
Medication Record Sheet (SH36AM).
a. Document on the Daily Medication List by
noting the date of when the medication was
discontinued, and initial.
b. If a medication is discontinued, document on
the back of the Monthly Medication Record
Sheet SH36AM all communication with
the parent(s)/legal guardian(s), PHN, etc., and
initial.
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Medications in School �Daily, Routine, Scheduled Medication Administration �(SHA 4-1-4 Cont’d)
c. Check the medication container label against the medical
provider’s order on the SH36. Check the medication expiration
date.
d. Consult with PHN if there are any discrepancies.
4. Always follow the 5 Rights in order to give the medication
safely.
Before administering the medication, compare the container
label and the SH36 to assure:
a. Right Student
b. Right Medication
c. Right Dosage
d. Right Time to be administered
e. Right Route
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Medications in School �Daily, Routine, Scheduled Medication Administration�(SHA 4-1-4 Cont’d)
5. Doses of the medication should always be given within 30
minutes of the time officially prescribed within the (30 minutes
before and 30 minutes after the window period). If unable to
administer within the window period, notify the parent(s)/legal
guardian(s) that the medication was not given, and follow the
medication error reporting procedure below (section VII).
6. Prepare medication for administration following
guidance/procedure for specific medication route (refer to
Medication Routes, 4-2). Always recheck the medication label
after preparation to confirm the correct dose prior to
administering the medication.
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Medications in School �Daily, Routine, Schedule Medication Administration�(SHA 4-1-4 Cont’d)
7. Confirm two (2) separate sources of information for
identification of the Right Student.
a. Ask the student for his/her full name and date of
birth.
b. The photo (if available) on the Monthly
Medication Record Sheet (SH36AM) may be
used as one (1) source of information to identify
the student.
c. A second DOE staff or agent that can confirm the
student’s full name may be used as one (1)
source of information to identify the student.
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Medications in School �Daily, Routine, Scheduled Medication Administration�(SHA 4-1-4 Cont’d)
d. Students with photo identification displaying their
full name and/or DOE Student ID number may be
used as one (1) source of info to identify the
student.
8. Give medication to the student.
C. Documentation
1. Refer to the instructions for the
Monthly Medication
Record Sheet (4-4).
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Medications in School �Emergency Rescue Medication Administration: Epinephrine, Inhalers, and Glucagon (SHA 4-1-4 and 4-1-5 Cont’d)
VI. Emergency Rescue Medication Administration:
Epinephrine, Inhalers, and Glucagon
A. Epinephrine, Inhalers, Glucagon, Valtoco or Nayzilam, as
defined as emergency rescue medication, may be administered
on an emergency basis.
1. Refer to Severe Allergy Management in School (5-2) for
Epinephrine orders.
a. Including any DOE employees or agents
interested in volunteering for administration
of auto-injectable epinephrine.
Revised 8/2024
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Medications in School �Emergency Rescue Medication Administration: Epinephrine, Inhalers, and Glucagon (SHA 4-1-5 Cont’d)
2. Refer to Asthma Management (5-3) for inhaler orders.
3. Refer to Diabetes Management in School (5-5) for Glucagon
orders.
a. Including any DOE employees or agents interested
in volunteering for administration of glucagon.
B. Administration of the Emergency Rescue Medication
1. Emergency Rescue Medication List (SH36ER):
a. Refer to documentation instructions, 4-7.
b. Update SH36ER as needed.
c. When a medication is discontinued, document the
date med was discontinued and initial.
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Medications in School �Emergency Rescue Medication Administration: Epinephrine, Inhalers, and Glucagon (SHA 4-1-5 Cont’d)
2. Emergency Rescue Medication Record Sheet (SH36ERP):
a. Refer to documentation instructions, 4-6.
b. If a medication is discontinued, document date when
medication was discontinued, and initial.
c. If any medication was given, complete documentation and
fax to PHN and call as needed.
3. Follow the student’s EAP. Always follow the 5 Rights in
order to give medication safely. Before administering the
medication, compare the container label and the SH36 or
SH36DM to assure:
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Administration of Daily, Routine, Scheduled Meds �(SHA 4-1-2 Cont’d):
a. Right Student
b. Right Medication
c. Right Dosage
d. Right Time
(1) For emergency medications, this may also be considered
the Right Reason.
e. Right Route
C. Documentation
1. Refer to the instructions for the Emergency Rescue Medication
Record Sheet (SH 36ERP). If the medication was not given, a
brief explanation must be documented on the Emergency
Rescue Medication Record Sheet (SH 36ERP).
Revised 8/2024
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Blood Glucose Monitoring
- Blood glucose meter.
- Blood glucose test strip.
- Lancing device.
- Lancet.
- Sharps container.
- Tissue or cotton.
- Alcohol swabs (only if there is no access to soap and water).
- Gloves.
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Revised 8/2024
Medication in School �Medication Errors or Concerns �(SHA 4-1-5)
VII. Medication Errors or Concerns
A. Consult the Administration and the PHN immediately when:
1. A medication error occurs, such as:
a. Wrong Student,
b. Wrong Medication,
c. Wrong Dosage,
d. Wrong Time and/or
e. Wrong Route.
2. Administration shall be responsible for completing any
Department required incident report, and may consult with
the PHN as needed.
Revised 8/2024
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Medications in School �Medication Errors or Concerns �(SHA 4-1-5 and 4-1-6 Cont’d)
3. The SHA or other individual responsible for the medication
administration error/concern shall log the event through the
School Health Section Google Form. Entries must be
completed for each individual occurrence of a medication
error.
B. If a medication being received appears different from previous
supply (e.g., different color, size, or shape, etc.):
1. Call the parent(s)/legal guardian(s) to confirm the medication
appearance.
2. Contact PHN if there is still a concern.
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Medication Errors or Concerns� (SHA 4-1-4 Cont’d):
C. For a missed administration of a Daily, Routine, Scheduled
Medication:
1. A missed administration for a Daily, Routine, Scheduled
Medication shall be considered a medication error when
the missed administration is not due to the student being
absent from school or failure of parent(s)/legal guardian(s)
to provide medication.
2. If the student is in school and fails to come in for his/her
daily dose, send a reminder to his/her teacher that he/she
is to be send to the health room at a particular time.
Revised 8/2024
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Medications in School �Medication Errors or Concerns �(SHA 4-1-6 Cont’d)
3. Call the parent(s)/legal guardian(s) if the
student does not come in for his/her daily dose
and document.
4. Notify the PHN and log the missed
administration event through the School Health
Section Google Form.
5. Notify the Administration if there is a need to
send 3 reminders to the student within one
week occurrence.
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DOE Request to Store and Administer Medications �(SH36, Revised 1/2024 - SHA 4-2A)
Parent’s/Legal Guardian’s request, authorization, and waiver of liability indicates that:
personnel of DOE, and their employees or agents, including nurses and their supervised delegates assigned by the DOE pursuant to written agreement.
Revised 8/2024
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DOE Request to Store and Administer Medications �(SH36, Revised 1/2024 - SHA-4-2A)
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SH 36 Revised 1/2024, �Page 2 (#1-11) (SHA 4-2A-1)
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Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024, Page 2 (SHA 4-2A-1)
Please note: School Health Assistants (SHA) are not licensed health professionals but are specifically trained in medication administration under predictable circumstances. They are not able to perform clinical assessments necessary which may be to determine the need for medication or response to medication. They are provided with protocols to follow in situations where the need for medication is explicit, straightforward and can be strictly defined.
Revised 8/2024
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�Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024, Page 2 (SHA 4-2A-1)�
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Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024, Page 2 (SHA 4-2A-1)
a. Epi-Pen or Glucagon: When administered, the school will call 911 and notify the parent/legal guardian. The school will defer to Emergency Medical Service (EMS) personnel with respect to whether transport to a medical facility is needed. If EMS personnel determine that transport to a medical facility is not needed, the parent/legal guardian will be informed to pick up the student.
b. Asthma quick-relief inhalers and emergency seizure medications: When administered by unlicensed personnel, the school will notify the parent/legal guardian to pick up the student. 911 may be called in cases required by the student’s condition or if indicated by the student’s individual Emergency Action Plan. In cases where a registered nurse (RN) is available to assess the student, the RN may determine that the student could otherwise safely remain in school. Parent/legal guardian will be notified of the RN’s assessment.
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�Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024 (Page 2 SHA 4-2A-1) �
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Notice to Parents/Legal Guardians and Healthcare Providers �SH36 Revised 1/2024, Page 2 (SHA 4-2A-1)
7. In order for medications to be stored in school and administered by the DOE SHA, the medications must:
a. Be dispensed by a pharmacist in accordance with
HRS §328-16(a)(1)-(11). This includes container/vial labeling with
the name of the student, name of the medication, strength and
instructions for use of the medication, and name of the
prescribing physician or other practitioner with prescriptive
authority;
b. The instructions of the container must be a completed Form
SH36 or SH36DM; and
c. Be designated on a completed and approved Form SH36 or
SH36DM.
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�Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024 (Page 2 SHA 4-2A-1) �
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�Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024 (Page 2 SHA 4-2A-1) �
9. In cases where a student with approved SH36 medication(s) is off campus to participate in a DOE sponsored activity, prior arrangements must be made between the parent/legal guardian and the school to ensure the student will received these medications.
Revised 8/2024
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�Notice to Parents/Legal Guardians and Healthcare Providers �SH 36 Revised 1/2024 (Page 2 SHA 4-2A-1) �
10. Any new medication order(s) or changes to a previously
approved SH36 form, will require a new “Request to
Store and Administer Medications” form (SH36),
Revised 2024) to be completed and approved as
specified in this form. However, prescription refills for
an approved SH36 medication request do not require a
new form.
11. This form is applicable only for the current school
year and must be renewed yearly. Parent/legal
guardian are responsible for submitting requests
for the following school year.
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Section II(a) Physician’s or Practitioner with Prescriptive �Authority’s Requested Orders for Emergency Rescue Medications (SH 36 Revised 1/2024, Page 3 - SHA 4-2A-2)
Revised 8/2024
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Section II(b). Physician’s or Practitioner with Prescriptive Authority’s Requested Orders for Daily, Scheduled Medications�(SH36 Revised 1/2024, Top of Page 4) (SHA 4-2A-3)
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Section II(b). Physician’s or Practitioner with Prescriptive Authority’s Requested Orders for Emergency As Needed (PRN) Medications (SH36 Revised 1/2024, Middle of Page 4) (SHA 4-2A-3)
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Section II(b). Physician’s or Practitioner with Prescriptive Authority’s Requested Orders for Daily, Scheduled Medications and/or Emergency As Needed (PRN) Medications �(SH36 Revised 1/2024, Top of Page 4) (SHA 4-2A-1)
Section III(b), Authorized Health Care Professional Approval or �Requested Medication Orders �(SH36 Revised 2021, Bottom of Page 4) (SHA 4-2A-3)
Administration of medication to the above named student as requested by the parent/legal guardian and prescribed above by the physician/practitioner:
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Medication Errors or Concerns �(SHA 4-1-4 Cont’d):
Medication that appears different from the previous supply (e.g., different color, size, or shape, etc.):
2. Contact PHN/HKN if there is still a concern.
Revised 1/2024
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Transfer In and Out �(SHA 4-1-4 Cont’d)
If a student with a current SH36 transfers IN from one school to another:
a. SHA to start a new Medication Record Sheet.
legal guardian(s) of the student indicate medications
were given at a previous school.
Revised 1/2024
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Transfer In and Out �(SHA 4-1-4 & 4-1-5 Cont’d):
If a student with a current SH36 transfers OUT from one school to another:
1. For immediate continuity, Fax the current SH36, the PHN
Consultation Report/Written Recommendation, and the EAP (if
applicable) to the receiving school. If the receiving school is
unknown, hold on to the documents until it is requested.
2. When the receiving school is known, give the following original
documents, if applicable: SH36, PHN Consultation Report/Written
Recommendation, Medication Record Sheets (SH36A, SH36AM, or
SH36ERP), and/or EAP to the office to forward to the receiving
school via the Cumulative (CUM) folder.
Revised 1/2024
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Filing of Forms� (SHA 4-1-5)
At the end of the school year, or at the time that the SHA last gave the medication to the student in school:
Revised 1/2024
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Extended School Year (ESY) �(SHA 4-1-5)
Extended School Year (ESY) is an extension of the prior school year, thus the SH36 may continue for Disabilities Education Act (IDEA) or special education students.
It is the responsibility of the DOE to make arrangements for the administration of medications to these students during ESY.
Revised 1/2024
66
Medication Routes �(SHA 4-2)
Purpose: To be familiar with the various ways how medications are administered to students.
Procedure:
Revised 1/2024
67
Medication Routes�(SHA 4-2 thru 4-2-3)
Revised 1/2024
68
Self-Administration of Medication (Act 214) (SHA 4-3A)
Revised 8/2024
69
Self-Administration of Medication (Act 214) (SHA 4-3A)
PURPOSE: HRS §302A-1164 allows for “the self-administration of medication by a student for asthma, anaphylaxis, diabetes, or other potentially life-threatening illnesses.”
Revised 1/2024
70
Self-Administration of Medication (Act 214)�(SHA 4-3A Cont’d):
Act 214 shall be kept at the school office and/or health room to be accessible for a parent(s)/legal guardian(s) upon request.
Revised 1/2024
71
Self-Administration of Medication, Act 214 �(SHA 4-3A Cont’d):
If a parent(s)/legal guardian(s) requests an Emergency Action Plan (EAP) or Individualized Emergency Action/Precautions Plan (IEAPP), the SHA to provide the PHN/HKN with family contact information.
Revised 1/2024
72
Self-Administration of Medication(s) and Glucagon List �(SHA 4-3B)
PURPOSE: To collect data on the number of students with self-administered medications and/or Glucagon.
Revised 1/2024
73
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4A and Sample on 4-4B)
74
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4A-1) Page Two and Sample SHA 4-4B-1)
75
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4)
Purpose: To provide SHAs with a document to record daily medications. To keep track of the amount of medication given to the SHA from the parent(s)/legal guardian(s), and to document when the medication was administered to the student.
Procedure
medication administration.
a. Student Name f. Dose
b. DOB g. Route
c. Gr/Rm h. Time
d. School Year i. Month
e. Medication j. Student Photo
76
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4 Cont’d)
2. Documenting Medication Administration
a. Time: Exact time mediation was administered.
b. Initials/Code: Write initials or appropriate code if Med was NOT
administered. Codes are as follows:
i. A: Absent
ii. E: Early release
iii. F: Field trip
iv. X: No school
v. NM: No medication. Student did not receive their med b/c no
med available to administer.
vi. NS: Med not administered b/c student did not report to HR.
vii. P: Med given by parent/legal guardian.
c. Daily Starting Pill Count: done on first day when med rec’d; and at
beginning of each day. Note number of pills remaining.
77
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4-1)
d. Initial/Printed Name: at bottom of page; person administering med
3. Continuation of Medication Administration
a. If SH36 med order is discontinued, as per Medication
Management in School (4-1) procedures, complete the following
steps on the current SH36AM:
i. Complete final pill count and document in Daily Starting Pill
Count for the day med is discontinued.
ii. Draw a horizontal line thru remaining rows on monthly
medication sheet.
iii. Document discontinuation using Additional Comments section
on back of SH36AM, including the method and date of
notification and individual requesting discontinuation.
78
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4-1 Cont’d)
4. Logging Medication Received/Returned
a. NO medications will be accepted or administered by DOE staff
without a completed PHN consultation report/written
recommendation and approved SH36.
b. IMPORTANT: Accept medication only when it is in a pharmacy
labeled contained, provided by parent(s)/legal guardian(s).
c. Medication label must state: name of student, name of medication,
dosage, time to be given, and name of medical provider.
d. Log medication received/returned on the back of the Monthly
Medication Record Sheet (4-4A-1) and have parent/guardian print
and sign.
79
Monthly Medication Record Sheet (SH 36AM) �(SHA 4-4-1 Cont’d)
5. Additional Comments
a. Comments: Use this section to note communication with parent/
legal guarding, PHN, etc. and for any additional information
related to student’s medication administration.
6. File the SH36AM (4-4A) with the SH36.
7. Refer to sample on page 4-4B.
80
Emergency Rescue Medication Record Sheet (SH 36ERP)�(SHA 4-6A and Sample SHA 4-6B)
81
Emergency Rescue Medication Rescue Sheet (SH 36ERP) (SHA 4-6)
PURPOSE: To record when an emergency rescue medication was administered to a student as well as the reason for giving it and the results after administration.
Date/Time/Reason & Results/Initial: Each time the emergency rescue medication needs to be administered; document date, time administered, reason for administering, and outcomes after administration. Initial entry.
Refer to the sample on SHA 4-6B.
Revised 1/2024
82
Emergency Rescue Medication List (SH 36ER) (SHA 4-7A)
Revised 1/2024
83
Emergency Rescue Medication List (SH 36ER) �(SHA 4-7)
PURPOSE: To keep a record of all students who have an emergency rescue medication in the school setting.
File the Emergency Rescue Medication List (SHA 4-7A) in the medication binder.
Complete an Emergency Rescue Medication List
(SHA 4-7A) every school year and update when:
Revised 1/2024
84
Memo to Teacher, SH 36T�(SHA 4-8A)
Revised 1/2024
85
Memo to Teacher, SH 36T �(SHA 4-8)
PURPOSE: To serve as a communication tool between the SHA and teacher regarding a student who is to receive medication in the school setting.
Revised 1/2024
86
Quiz
Revised 1/2024
87
Quiz, Cont’d
Revised 1/2024
88