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Authorization for an Injectable Medication

This form is to authorize the staff of A Helping Hand Senior Care Services LLC to administer specific Injectable medications as indicated below. Unlicensed staffs are not able to administer psychotropic medications by injection under any circumstances. The following Injectable medications have been authorized at signing:

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245D.05 HEALTH SERVICES Subd. 5 Injectable medications may be administered according to a prescriber’s order and written instructions when one of the following conditions has been met:

    (1) a registered nurse or licensed practical nurse will administer the subcutaneous or intramuscular injection n;
    (2) a supervising registered nurse with a physician’s order has delegated the administration of subcutaneous Injectable medication to an unlicensed staff member and has provided the necessary training; or
    (3) there is an agreement signed by the license holder, the prescriber, and the person or the person’s legal representative specifying what subcutaneous injections may be given, when, how, and that the prescriber must retain responsibility for the license holder’s giving the injection.

All medication administration errors will be reported to the prescribing physician as requested by the physician. The signatures below approve unlicensed staff to administer the specified Injectable medications as prescribed and in accordance with the written instructions.

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