Get the free Naloxone Reporting Form - Riverside - REMSA.US
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Central Valley Health DistrictOpioid Overdose/Narc a Refill Form Name: ___ Signature: ___Date: ___ ___ / ___ ___ / ___ ___1.a. Was naloxone (Narc an) administered to reverse an overdose? Yes (Skip
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How to fill out naloxone reporting form
How to fill out naloxone reporting form
01
Obtain a naloxone reporting form from the appropriate healthcare facility or organization.
02
Fill out the patient's information, including name, date of birth, and contact information.
03
Document the details of the naloxone administration, such as date and time, dosage given, and any adverse reactions experienced.
04
Provide any additional relevant information, such as the reason for administering naloxone or any follow-up care provided.
05
Submit the completed naloxone reporting form to the designated entity for tracking and monitoring purposes.
Who needs naloxone reporting form?
01
Healthcare professionals who administer naloxone to patients in emergency situations.
02
Organizations or facilities that distribute naloxone kits to individuals at risk of opioid overdose.
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What is naloxone reporting form?
Naloxone reporting form is a form used to report the administration of naloxone, which is an opioid overdose reversal medication.
Who is required to file naloxone reporting form?
Healthcare providers, first responders, and other professionals who administer naloxone are required to file naloxone reporting form.
How to fill out naloxone reporting form?
The naloxone reporting form typically requires information such as the date and time of administration, the individual receiving the naloxone, and any other relevant details.
What is the purpose of naloxone reporting form?
The purpose of naloxone reporting form is to track the use of naloxone, monitor overdose trends, and improve public health interventions.
What information must be reported on naloxone reporting form?
Information such as the date and time of naloxone administration, the individual receiving the naloxone, and the dosage administered must be reported on naloxone reporting form.
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