"Over the Counter Medication Form" - Delaware

This "Over the Counter Medication Form" is a part of the paperwork released by the Delaware Health and Social Services specifically for Delaware residents.

The latest fillable version of the document was released on May 26, 2016 and can be downloaded through the link below or found through the department's forms library.

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Download "Over the Counter Medication Form" - Delaware

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DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COMMUNITY SERVICES
OVER-THE COUNTER MEDICATION ORDERS
Individual’s Name:
MCI Number:
Drug Allergies:
Home Name and Address:
ATTENTION STAFF: Whenever you assist with any of the medications from this form, you must sign the
MAR, and document usage and effectiveness in the electronic record.
NON-EMERGENCY CONDITIONS: Non-Prescription Medications
1.
HEADACHE OR MINOR ACHES AND PAINS:
Acetaminophen / Tylenol
Dose: Two 325mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
Call Health Care Provider if headache persists for 24 hours, if it occurs more than 3 times
per week, or if it becomes intense, incapacitating, or no relief is obtained from the
medication. Also, call Health Care Provider if body aches continues over 24 hours.
2.
MENSTRUAL CRAMPS: (Females Only)
Advil / Ibuprofen
Dose: Two 200mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
3.
TEMPERATURE ELEVATION:
Acetaminophen/Tylenol
Dose: Two 325 mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
To be given when oral temperature is over 100° F or axillary temperature is over 99°F.
Call Health Care Provider if fever persists over 24 hours or if it is accompanied by vomiting and /
or diarrhea, increased coughing or congestion, headache, or abdominal pain that does not stop.
Notify the Health Care Provider sooner if an increased temperature / fever is accompanied by
increased coughing, congestion, or difficulty breathing.
4.
MINOR ABRASIONS OR CUTS:
Clean area with soap and water then apply Antibiotic ointment topically to the area. May cover with a
if needed. Apply twice a day until healed.
Band-Aid
If affected area worsens (increased redness, drainage, warmth, swelling, etc.) during above
treatment, notify Health Care Provider.
Prescribing Health Care Provider’s Signature
Date
5/26/16
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
COMMUNITY SERVICES
OVER-THE COUNTER MEDICATION ORDERS
Individual’s Name:
MCI Number:
Drug Allergies:
Home Name and Address:
ATTENTION STAFF: Whenever you assist with any of the medications from this form, you must sign the
MAR, and document usage and effectiveness in the electronic record.
NON-EMERGENCY CONDITIONS: Non-Prescription Medications
1.
HEADACHE OR MINOR ACHES AND PAINS:
Acetaminophen / Tylenol
Dose: Two 325mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
Call Health Care Provider if headache persists for 24 hours, if it occurs more than 3 times
per week, or if it becomes intense, incapacitating, or no relief is obtained from the
medication. Also, call Health Care Provider if body aches continues over 24 hours.
2.
MENSTRUAL CRAMPS: (Females Only)
Advil / Ibuprofen
Dose: Two 200mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
3.
TEMPERATURE ELEVATION:
Acetaminophen/Tylenol
Dose: Two 325 mg Tablets
Frequency: Every 4 hours as needed
Route: By Mouth
To be given when oral temperature is over 100° F or axillary temperature is over 99°F.
Call Health Care Provider if fever persists over 24 hours or if it is accompanied by vomiting and /
or diarrhea, increased coughing or congestion, headache, or abdominal pain that does not stop.
Notify the Health Care Provider sooner if an increased temperature / fever is accompanied by
increased coughing, congestion, or difficulty breathing.
4.
MINOR ABRASIONS OR CUTS:
Clean area with soap and water then apply Antibiotic ointment topically to the area. May cover with a
if needed. Apply twice a day until healed.
Band-Aid
If affected area worsens (increased redness, drainage, warmth, swelling, etc.) during above
treatment, notify Health Care Provider.
Prescribing Health Care Provider’s Signature
Date
5/26/16
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