Naloxone Dispensing and Standing Order Documentation

Documents naloxone dispensing under a standing order and the associated patient education, counseling, and minimum-necessary dispensing details.

Dispensing Event

• Dispense Date
• Dispense Time
• Dispensing Location
• Recipient Type
• Was this dispensed under a standing order?
• Standing Order Reference
  Enter the standing order identifier or internal reference number if applicable.
• Naloxone Product/Formulation
• Quantity Dispensed

Recipient and PII Disclosure

• Recipient Name
  Optional. Collect only if needed for your dispensing workflow or audit trail.
• Recipient Contact Information
  Optional. Use only if needed for follow-up or program documentation.
• Consent to collect and store the above PII for dispensing documentation and follow-up, if needed
  Only collect PII that is necessary for this workflow. If you do not need identifiers, leave these fields blank.

Patient Education and Counseling

• Was counseling or education provided?
• Education Topics Covered
• Education Method
• Teach-back completed successfully?
• Counseling Notes
  Document any key points, questions answered, or barriers to understanding.

Outcome, Refusal, and Follow-up

• Was naloxone accepted?
• Reason for refusal
• Follow-up needed?
• Follow-up Action
• Follow-up Notes

Attestation

• Documented By
• Role / Title
• I attest that this record accurately documents the naloxone dispensing event and any education provided.