506.2.2.1P - Somali Authorization for Administration of Medication at School

Medication Order 

This section must be completed by the health care provider when medication is prescribed for more than two weeks OR is a controlled medication

Medication

ICD-10/Diagnosis

Dose

Time

Route

1.

2.

3.

Signature of health care provider                                                                                               

Print name of health care provider                                                                                               

Date                               

Clinic name                                                                                                

Clinic phone                                                                

Clinic fax                                                                                                                                                                                     

Oggolaanshaha Waalidka/Wakiilka

1.   Waxaan codsanayaa in daawada korku xusan la siiyp saacadaha dugsiga sida uu ii goray bixiyaha xanaanada caafimaadka ilmahayga.

2.   Waxaan ogaysiin doonaa kalkaalisada isbedel kasta oo ku yimaadda daawooyinka, tusaale ahaan, beddelka giyaasta, daawada la joojiyp, iwm.

3.   Waxaan fasaxay in daawadu ay bixiyaan shaqaale u tababaran dugsiga marka ay u wakiisho degmada 196 kalkaalisada diiwaangashan.

4.   Waxaan ka dhaafayaa shaqaalaha iskuulka mas'uuliyadda haddii ay dhacdo falcelin xun oo ka dhalata qaadashada daawada.

5.   Waxaan fahamsanahay in ay tahay in aan ku keeno dawadan dahalada dhakhtar goray ee asalka ah.

6.   Waxaan fahamsanahay in layga baahan yahay inaan soo saaro walxaha la xakameeyey marka uu dugsigu codsado

7.    Waxaan u magacaabay degmada dugsiga inay tahay hay'ad idman inay rarto walxaha aan la xakameynin ujeeddooyinka burburinta haddii xaddi aan la isticmaalin ay ku harto gacanta shaqaalaha dugsiga

8. Waxaan u fasaxay kalkaalisada dugsiga inay kala hadasho, hadba sida loogu baahdo, shaqaalaha dugsiga xaaladaha caafimaad ee ilmahayga iyo isticmaalka daawooyinka.

9. Waxaan u fasaxay kalkaalisada iyo bixiyaha xanaanada caafimaadka in ay bixiyaan macluumaadka oo ay midba midka kale ka codado macluumaadka la xiriira daawooyinka iyo xaaladaha caafimaad eek or ku xusan. Diiwaanada caafimaakda, ee ay gacanta ku hayso demada dugsi, waxa laga yaabaa in aan lagu ilaalin Xeerka Qaadida iyo La Xisaabtanka Caymiska Caafimaadka (HIPAA), laakiin waxa ay nogonayaan diiwaannada waxbarashada oo uu ilaaliyo Xeerka Xuquuqda Waxbarashada Qoyska iyo Gaarka ah.

Oggolaanshahani waxa uu dhaqan galayaa maalinta aan saxeexo oo waxa uu dhacayaa hal sano laga bilaabo taariikhda aan saxeexay. Sharci ahaan waxaa laga yaabaa inaan diido inaan saxiixo oggolaanshahan. Waxaan fahamsanahay in oggolaanshanhan laga yaabo in la buriyo wakhti kasta iyadoo ogeysiis qoraal ah loo diro kalkaalisada. Haddii aan diido inaan saviixo, ama aan ka noqdo oggolaanshaha, adeegyadan lagama yaabo in lagu bixiya dugsiga.

Saxeexa Waalidka                                                       Taa                         

Office Use:

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