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Run: Naloxone Dispensing and Standing Order Documentation

Naloxone Dispensing and Standing Order Documentation records each naloxone dispense, the standing order used, product details, and counseling provided in one...

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Dispensing Event Details

Dispense Date (required)

Date naloxone was dispensed.

Dispense Location (required)

Location where the naloxone was provided.

Standing Order / Protocol Reference (required)

Reference identifier for the standing order or protocol used to authorize dispensing.

Reason for Dispensing (required)

If Other, describe

Patient or Recipient Information

Recipient Type (required)

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 (required)

Confirm that eligibility was verified according to the standing order or local policy.

Yes No N/A

Naloxone Product Dispensed

Naloxone Product Form (required)

If Other, describe product form

Product Name / NDC (required)

Enter the product name or package identifier used in inventory tracking.

Quantity Dispensed (required)

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 (required)

Education Method (required)

Recipient Demonstrated Understanding (required)

Additional Counseling Notes

Use only if needed to document clinically relevant counseling details.

Staff Attestation

Staff Name (required)

Name of the person documenting the dispensing event.

Staff Role (required)

If Other, describe role

Attestation (required)

I attest that naloxone was dispensed under the applicable standing order or protocol and that education was provided as documented.

Yes No N/A

Recipient Acknowledgment Received

Check if the recipient signed or otherwise acknowledged receipt, if your workflow requires it.

Yes No N/A

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