•	To be completed by the foster carer on all occasions when any medication is regularly given – prescribed and non-prescribed;
•	Non-prescribed medication - (see section in Fostering Handbook on home remedies if unsure about when to use non-prescribed medication).  Such medication will include items such as Calpol, linctus paediatric/simple linctus, paracetamol, ibuprofen;
•	Please complete in ink and clearly, so that the writing can be read by others;
•	PRN means “as required”.
AN EXAMPLE OF COMPLETED MEDICATION IS ON THE NEXT PAGE
Please outline any foods or drinks which cannot be taken with any of the medication and any intolerances:	
	Cannot be taken with		
	Cannot be taken with		
Intolerances are:		

Route = route of administration:  O = Oral; E = External; I = Injection; W = With Food

Name of Child	Date of Birth	Service User Number		
Routine prescribed/ administered medication	Date	Route	Times and initials of carer	

									

									

									

									

									

									

									

									

									

									
									
Routine regular medication and dosage as prescribed/administered	

Handover (where appropriate)	Yes/No	Signature	Name (foster carer) and date	
Is this form fully up-to-date?				
Form received by me today:				
Quality Assurance	Yes/No			
Form – any comments/further action needed			Name (Child’s Social Worker) and date	
Form – any comments/further action needed			Name (Supervising Social Worker) and date	

EXAMPLE OF ROUTINE MEDICATION FOR JOE BLOGGS WHO HAS FOUR DIFFERENT TYPES OF MEDICATION, FOUR TIMES A DAY:
Name of Child: Joe Bloggs	Date of Birth: 04.02.2002	Service user number: 123456	
Medication and date prescribed	Dose	Frequency	Comments	
Domperidone 03.02.10	0.7 ml	4 times a day	Before meals, syringed into his mouth	
Gaviscon 04.02.10	1 sachet	4 times daily	Added to drinks (with his milk)	
Dalivit 05.02.10	0.6 ml	Once a day	Syringed into his mouth	
Hydrocortisone cream 06.02.10	PRN	PRN	Rubbed onto affected area as required.	

EXAMPLE OF COMPLETED RECORD BELOW FOR JOE BLOGGS

Routine prescribed/administered medication	Date	Route	Time and initials of carer	
			08:00	12:00	16:00	20:00			
Domperidone 0.7 ml	12/02/10	O	DP	DP	DJP	MP			
Gaviscon 1 sachet	12/02/10	O	SD	DP	DJP	DP			
Dalivit 0.6 ml	12/02/10	O			DJP				
Hydrocortisone cream PRN	12/02/10	E	DP		DP