FQHC

P&P - Naloxone Training and Prescribing

Naloxone: Training, Prescribing, and Dispensing

Purpose: Opioid overdose is a rising concern in Baltimore City and nationwide. Naloxone is a nationally recognized overdose response intervention that can reverse an overdose caused by the ingestion of an opioid. [FQHC]) is designated as an Overdose Response Program (ORP) by the Maryland Behavioral Health Administration. This designation allows for all staff of [FQHC] to educate and certify individuals on the steps to administer naloxone and provide a prescription for naloxone that can be filled under the Naloxone Standing Orders.

Procedure:

For Individuals enrolled in [FQHC] Electronic Health Records:

1)Staff trained as trainers on the administration of naloxone will conduct either a brief or hour-long training on the signs and symptoms of opioid overdose and the steps to administering naloxone.

2)Client will complete a Trainee Application for Certificate (below).

3)Clients will be provided with a “Save A Life” card that contains a certification number and pouch with written instructions on administering naloxone. Certifications are valid for 2 years from date of issue.

4)Staff will record the certification number in client’s chart in the Electronic Health Record system.

5)All individuals carrying a valid “Save A Life” card issued by an ORP can receive naloxone doses without a written prescription at any pharmacy in Baltimore City. Individuals who are clients of [FQHC] and fill their prescriptions at ______Pharmacy.

For Individuals not enrolled in [FQHC] Electronic Health Records:

1)Staff trained as trainers on the administration of naloxone will conduct a brief or hour-long training on the signs and symptoms of opioid overdose and the steps to administering naloxone.

2)Individual will complete a Trainee Application for Certificate (below).

3)Individual will be provided with a “Save A Life” card that contains an certification number and pouch with written instructions on administering naloxone. Certifications are valid for 2 years from date of issue.

4)Staff will record the certification number and individual’s name on the attached form and return it to the Director of Community Services.

5)All individuals carrying a valid “Save A Life” card issued by an ORP can receive naloxone doses without a written prescription at any pharmacy in Baltimore City. Trained individuals that are not patients of [FQHC] will be responsible for any costs affiliated with filling the prescription.

To Receive a Replacement Card

Individuals who lose their certification card while their certification is still valid can contact any trained[FQHC] staff to receive a replacement. Replacement cards should have the same certification number and expiration date as the one originally issued.

Recertification Process for Expired Cards

To complete recertification, individuals should complete the above steps and be issued a new “Save A Life” card with the same certification number (when possible) and a new expiration date.


Applicant Name:

First Middle Last

Street Address: ______

City, State, Zip:______

Date of Birth:______/______/______(Applicant must be at least 18 years old)

(Month/day/year)

E-mail Address (optional): ______Phone Number (optional): ______

Sex (optional): Male Female Not Stated

Race/Ethnicity (optional) check all that apply:

American Indian or Alaskan Native

Black or African American

Native Hawaiian or Other Pacific Islander

White or Caucasian

Asian

Are you Hispanic or Latino? Yes No

Please check which category bestdescribes your reason to receive a certificate:

Occupation  Volunteer Work  Family Member Social Experience Law Enforcement

I hereby certify that the information contained in this application is complete and accurate to the best of my knowledge.

Applicant Signature:______Date:______

FOR ORP USE ONLY:

Trainee eligible to receive:  Certificate  Prescription for naloxone Naloxone

Certificate Serial Number:
___HCH-______
Certificate Issuance Date:
______
Certificate Expiration Date:
______/ Prescription (if applicable):
Prescriber Name:
______
Prescription Number:
______/ Naloxone (if applicable):
Naloxone Lot Number:
______
Naloxone Expiration Date:
______
# Doses: ______ Intranasal Intramuscular
Dispensed by:
______

Date of Training: ______Location of Training: ______

ORP Proficiency Quiz for Certificate Renewal