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Run: Naloxone Dispensing and Standing Order Documentation

Track naloxone dispensing under a standing order with eligibility, consent, product details, and counseling in one record. Use it to document what was dispen...

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Dispensing Context

Dispense Date (required)

Date naloxone was dispensed.

Dispensing Location (required)

Location or site where the naloxone was dispensed.

Standing Order Reference (required)

Internal standing order, protocol, or authorization reference.

Dispensed By (required)

Name and role of the staff member completing the dispense.

Patient Eligibility and Consent

Patient Type (required)

Select the dispensing context.

Eligible Under Standing Order (required)

Confirm the dispense is authorized under the applicable standing order.

Patient Name

Optional. Collect only if needed for your workflow or audit trail.

Patient Contact Information

Optional. Use only if follow-up or counseling contact is necessary.

Consent to Receive Naloxone and Education (required)

Document consent/disclosure acknowledgment before dispensing.

Yes No N/A

Product Dispensed

Product Form (required)

Select the naloxone formulation dispensed.

Product Name (required)

Brand or product name.

Strength / Concentration (required)

Document the labeled strength or concentration.

Quantity Dispensed (required)

Number of units dispensed.

Lot Number

Optional. Collect if required for inventory or recall tracking.

Expiration Date

Optional. Use if your workflow tracks product expiration.

Education and Harm Reduction Counseling

Education Topics Covered (required)

Select all topics reviewed with the patient.

Patient Demonstrated Understanding (required)

Document whether the patient understood the instructions.

Teach-Back Completed

Optional. Use if teach-back was performed.

Additional Counseling Notes

Document any relevant counseling details, barriers, or follow-up needs.

Attestation and Submission

Attestation (required)

Required attestation for documentation integrity.

Yes No N/A

Follow-Up Needed (required)

Indicate whether follow-up is needed.

Follow-Up Reason

Explain why follow-up is needed.

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