Date: _________________
Physician’s Name: _______________________________
Youth’s Name: ________________________________________________________________
ALERT: Before giving any medicines included in these standing orders confirm with the
youth’s prescribing doctor to make sure there are no interactions with a medicine that has already
been prescribed, including psychotropic medications or maintenance medications for chronic
conditions.
ALERT: Be careful with any youth with a history of allergies to insects, peanuts, chocolate,
shellfish, antibiotics or any other life-threatening allergy. Any potential allergic reaction is to be
considered an emergency. Call 911 immediately.
ALLERGIES: _______________________________________________________________
_____________________________________________________________________________
CURRENT MEDICATIONS: ___________________________________________________
_____________________________________________________________________________
______________________________________________
Date: _______________________
Physician/Nurse Practitioner Signature
______________________________________________
Date: _______________________
Domus Administrator Signature
THESE STANDING ORDERS EXPIRE ON: _______________________________________________
90 days from Physician Signature
Resident Name: _____________________
D.O.B. __________
Medication
Guaifenesin cough syrup
Active ingredient:
guaifenesin
Dose
Common Cold
symptoms such as
runny nose, NO fever,
dry cough , sore throat
Frequency
(concentration 100mg
/ 5ml); may give 200
mg/ two teaspoons
(10ml)
Guaifenesin
Cough, dry cough
(concentration 100mg
/ 5ml); may give 200
mg/ two teaspoons
(10ml)
Cepacol lozenges
Dry throat, dry cough
One lozenge
Acetaminophen
Ear Ache
650 mg by mouth
Acetaminophen
Fever of 99-100.5 oral
650 mg by mouth
Active ingredient:
guaifenesin
Resident Name: _____________________
Instruction
Give every four hours,
as needed, for cough.
Not to exceed six
doses per 24 hour
period. Wash hands
often. Get extra rest
and sleep. Drink extra
fluids of water, diluted
juice per day. If
symptoms continue
for more than 2 days,
or if fever, seek
medical attention.
Give every four hours,
as needed, for cough.
Not to exceed six
doses per 24 hour
period. Drink extra
fluids everyday. Seek
medical attention if
continues >2 days.
Give one lozenge
every two hours, as
needed, for dry throat
and/or dry cough; do
not exceed more than
ten in 24 hours.
Every four hours, as
needed, for
discomfort; not to
exceed 8 tablets in 24
hours. If pain
continues for more
than one day, or if
drainage from ear, or
ringing in ear, seek
medical attention.
Every four hours, as
needed, for fever; do
not take more than 8
tablets in 24 hours. If
fever for more than 24
hours or greater than
100.5 oral, seek
medical attention.
D.O.B. __________
Medication
Acetaminophen
Dose
Headache
Frequency
650 mg by mouth
Acetaminophen
Minor Muscle Ache
650 mg by mouth
Acetaminophen
Toothache
650 mg by mouth
Maalox Regular Strength
Sour
Stomach/Indigestion
200mg/5ml (per
teaspoon)
Resident Name: _____________________
Instruction
Every four hours, as
needed, for headache;
do not take more
than 8 tablets in 24
hours. If not relieved
after one day or
associated with nausea
or vomiting, or visual
changes, seek medical
attention.
Every four hours, as
needed for discomfort
or swelling; do not
take more than 8
tablets in 24 hours. If
continues for more
than 2 days, seek
medical attention.
Every four hours, as
needed, for tooth ache.
Do not exceed more
than 8 tablets in 24
hour period. If
toothache continues
after one day, seek
dental appointment as
soon as possible.
2 teaspoons, by
mouth, every two
hours, as needed for
sour stomach or
indigestion. Do not
exceed more than 16
teaspoons in 24 hour
period. If stomach
symptoms continue
for more than 24 hours
or worsen or are not
relieved by
medication, seek
medical attention
immediately. If
accompanied with a
fever or vomiting,
seek medical attention.
D.O.B. __________