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Run: Naloxone Dispensing and Standing Order Documentation

Document naloxone dispensing under a standing order, plus the product details, counseling, consent, and follow-up in one record. Use it to keep dispensing en...

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Dispensing Encounter

Date of Dispensing (required)

Select the date naloxone was dispensed.

Time of Dispensing

Optional time of dispensing for audit trail purposes.

Dispensing Location (required)

Select where the naloxone was dispensed.

Recipient Type (required)

Identify who received the naloxone kit.

Relationship to Patient

If the recipient is not the patient, describe the relationship.

Standing Order or Protocol Reference (required)

Enter the standing order, protocol, or policy reference used for dispensing.

Naloxone Product Details

Naloxone Formulation (required)

Select the naloxone formulation dispensed.

Brand Name

Optional brand name if applicable.

Strength / Concentration

Optional product strength or concentration.

Quantity Dispensed (required)

Enter the number of naloxone units or kits dispensed.

Lot Number

Optional lot number for inventory and traceability.

Expiration Date

Optional expiration date of the dispensed product.

Education and Counseling

Was naloxone counseling offered? (required)

Indicate whether counseling was offered at the time of dispensing.

Was counseling accepted? (required)

Record whether the recipient accepted counseling.

Education Topics Covered

Select all topics covered during education.

Education Method

Select how education was delivered.

Teach-back completed?

Indicate whether the recipient demonstrated understanding using teach-back.

Education Notes

Document any additional counseling details, questions asked, or barriers identified.

Safety, Consent, and Follow-up

Consent / Disclosure Acknowledged (required)

Confirm that required disclosure language was provided before collecting any PII.

Yes No N/A

Were any safety concerns identified? (required)

Indicate whether any immediate safety concerns were identified during the encounter.

Safety Concern Details

Describe the concern using minimum necessary detail.

Referrals Made

Select any referrals or follow-up actions provided.

Follow-up Needed? (required)

Indicate whether follow-up is needed after this encounter.

Follow-up Plan

Describe the follow-up plan, owner, and timing.

Staff Attestation

Staff Name (required)

Enter the name of the staff member completing the record.

Staff Role (required)

Enter the staff member's role or credential.

Attestation (required)

Confirm the accuracy of the record and the dispensing authorization.

Yes No N/A

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