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Medication Treatment Log
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(Per WI 78.27-5b, records are required to be retained for 3 years)
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Unit #:
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Activity/Event:
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Duration:to
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DateDate
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Health Service Staff
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Units must designate an adult as their Health Service Staff who is responcible for administering medication and provide
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first aid treatment during the duration of their stay. A Health Service Staff is required to have the following training:
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1) Certified CPR/AED (current)
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2) Certified First Aid (current)
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3) Completion of WI DPI Oral Medicine Administration Video & Quiz
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https://media.dpi.wi.gov/sspw/av/bmap/story_html5.html
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4) Medication is secured in a locked container that is only accessible by the designated Health Service Staff
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Health Service Staff Initials
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HEALTH SERVICE STAFF #1 (required)
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Name:
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Address:
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City: ____________________
ST: ____________
ZIP: ________
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Telephone:
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HEALTH SERVICE STAFF #2 (optional)
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Name:
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Address:
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City: ____________________
ST: ____________
ZIP: ________
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Telephone: Page 1
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