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Run: Naloxone Dispensing and Standing Order Documentation

Naloxone Dispensing and Standing Order Documentation records each naloxone dispense event, the standing order used, counseling provided, and any follow-up or...

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Dispensing Event

Dispense Date (required)

Dispense Time (required)

Dispensing Location (required)

Recipient Type (required)

Was this dispensed under a standing order? (required)

Standing Order Reference

Enter the standing order identifier or internal reference number if applicable.

Naloxone Product/Formulation (required)

Quantity Dispensed (required)

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.

Yes No N/A

Patient Education and Counseling

Was counseling or education provided? (required)

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? (required)

Reason for refusal

Follow-up needed? (required)

Follow-up Action

Follow-up Notes

Attestation

Documented By (required)

Role / Title (required)

I attest that this record accurately documents the naloxone dispensing event and any education provided. (required)

Yes No N/A

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Email (required)

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