Naloxone Dispensing and Standing Order Documentation

Documents naloxone dispensing under a standing order, including patient eligibility, product details, education provided, and attestation of counseling.

Dispensing Event Details

• Dispense Date
  Date naloxone was dispensed.
• Dispense Location
  Location where the naloxone was provided.
• Standing Order / Protocol Reference
  Reference identifier for the standing order or protocol used to authorize dispensing.
• Reason for Dispensing
• If Other, describe

Patient or Recipient Information

• Recipient Type
• Recipient Name
  Optional if your workflow requires identification for the audit trail.
• Recipient Contact Information
  Optional contact information if needed for follow-up or record matching.
• Age or Eligibility Verified
  Confirm that eligibility was verified according to the standing order or local policy.

Naloxone Product Dispensed

• Naloxone Product Form
• If Other, describe product form
• Product Name / NDC
  Enter the product name or package identifier used in inventory tracking.
• Quantity Dispensed
  Number of units dispensed.
• Lot Number
  Optional lot number for inventory or recall tracking.
• Expiration Date
  Optional expiration date if tracked by your workflow.

Education and Counseling

• Education Provided
• Education Method
• Recipient Demonstrated Understanding
• Additional Counseling Notes
  Use only if needed to document clinically relevant counseling details.

Staff Attestation

• Staff Name
  Name of the person documenting the dispensing event.
• Staff Role
• If Other, describe role
• Attestation
  I attest that naloxone was dispensed under the applicable standing order or protocol and that education was provided as documented.
• Recipient Acknowledgment Received
  Check if the recipient signed or otherwise acknowledged receipt, if your workflow requires it.