DJJ Form HS019 "Medication Administration Record/ Medication and Treatment Record (MAR)" - Florida

Form HS019 or the "Medication Administration Record/ Medication And Treatment Record (mar)" is a form issued by the Florida Department of Juvenile Justice.

The form was last revised in October 1, 2006 and is available for digital filing. Download an up-to-date Form HS019 in PDF-format down below or look it up on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form HS019 "Medication Administration Record/ Medication and Treatment Record (MAR)" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
0 =
Not Administered
Codes:
MEDICATION ADMINISTRATION RECORD/
Not to be Given
X =
Print Form
MEDICATION AND TREATMENT RECORD (MAR)
Refusal
R =
List Allergies/Common Side Effects/Precautions:
Medication Holiday
H =
Home Visit
HV =
No Side Effects
Ø =
/
SE =
Side Effects (See Nurses Note)
Month
Year:
Nurse/Staff Initials/
NI
Physician:
Youth Initials
YI
/
2
Medication
TX
Time
1
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22
23
24 25 26 27 28 29 30 31
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
/
Signature Nurse
Staff
Initials
Print Name
Signature Nurse/Staff
Initials
Print Name
Youth Name _____________________________
DJJID # ___________________DOB__________
Facility _________________________________
/
Diagnosis
Medical Grade _________________
/
Med
MH Alerts ___________________________
10/06
63M-2
Youth Signature and Initials
__________________________________________________________________
Page 1 of 1
Form 019
Save As
Reset/Clear Form
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
0 =
Not Administered
Codes:
MEDICATION ADMINISTRATION RECORD/
Not to be Given
X =
Print Form
MEDICATION AND TREATMENT RECORD (MAR)
Refusal
R =
List Allergies/Common Side Effects/Precautions:
Medication Holiday
H =
Home Visit
HV =
No Side Effects
Ø =
/
SE =
Side Effects (See Nurses Note)
Month
Year:
Nurse/Staff Initials/
NI
Physician:
Youth Initials
YI
/
2
Medication
TX
Time
1
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22
23
24 25 26 27 28 29 30 31
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
Start___________ Stop____________
Transcriber Init __________________
Side Effects Monitoring
/
Signature Nurse
Staff
Initials
Print Name
Signature Nurse/Staff
Initials
Print Name
Youth Name _____________________________
DJJID # ___________________DOB__________
Facility _________________________________
/
Diagnosis
Medical Grade _________________
/
Med
MH Alerts ___________________________
10/06
63M-2
Youth Signature and Initials
__________________________________________________________________
Page 1 of 1
Form 019
PRN Medications
TEMP.
PULSE
RESPIRATORY
RATE
BLOOD
PRESSURE
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31
TIME
TIME
NURSES
DATE
MEDICATION & DOSAGE
INJ. SITE
REASON
RESULTS OR RESPONSE
GIVEN
NOTED
SIGNATURE/TITLE
WEEKLY MAR REVIEW
DATE
SIGNATURE
PRINT NAME
TITLE
Rev. 10/06
63M-2
HS 019
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