Healthcare Epinephrine Resolution

HEALTHCARE EPINEPHRINE RESOLUTION

This Epinephrine Resolution documents the informed authorization and directive concerning the possession and administration of epinephrine for emergency treatment of anaphylaxis for the individual identified below. Facility Name: Location: Effective Date:

Patient Information

Date of Birth:   Gender:   Weight:

Phone:   Emergency Contact:   Phone:

Insurance & Prescribing Clinician

Policy Number:   Group Number:

Medical History & Allergies

Prior Anaphylactic Reaction:   If yes, provide date and description:

History of Asthma or Reactive Airway Disease:   Cardiovascular Disease:

Authorization and Conditions

I hereby authorize Facility Name identified above and its trained personnel to possess and administer epinephrine to the patient identified in this document in the event of a suspected anaphylactic reaction. Authorization is granted pursuant to the standing order of the prescribing clinician named above and applicable law. This authorization specifically permits:

1. Administration of intramuscular epinephrine at the dosage and route indicated by the standing order based on patient's weight and clinical presentation.
2. Activation of emergency medical services and transport to definitive care when clinically indicated.
3. Documentation of the event, medication lot number and expiration, and notification to the prescribing clinician and patient or guardian.

I acknowledge that administration of epinephrine carries risks and benefits. I understand that epinephrine is indicated for life‑threatening allergic reactions and that delaying administration may increase risk of harm. I further understand that epinephrine may cause transient side effects including, but not limited to, elevated heart rate, palpitations, anxiety, headache, tremor, and elevated blood pressure.

I authorize the facility to store on site epinephrine autoinjector(s) or equivalent epinephrine delivery devices and to replace them as necessary. I authorize facility personnel to use a non-patient-specific epinephrine supply when patient-specific supply is not available and emergency treatment is required, consistent with the prescribing clinician's standing order.

Consent, Release and Right to Withdraw

By signing below I certify that I am the patient or the legal guardian of the patient and that I have authority to grant this authorization. I consent to emergency administration of epinephrine as set forth above and release Facility Name, its employees and agents from civil liability for administering or declining to administer epinephrine in good faith and with reasonable care, except in cases of gross negligence or willful misconduct.

I understand this authorization may be revoked at any time by notifying Facility Name in writing. Revocation will not affect actions taken in reliance on this authorization before receipt of written revocation.

Authorization Expiration Date:

HIPAA Acknowledgment & Records

I acknowledge that medical information concerning the administration of epinephrine will be recorded in the patient's medical record. I consent to necessary disclosures to emergency responders, the prescribing clinician, and other healthcare providers involved in continuing care.

 I acknowledge receipt of this Epinephrine Resolution and consent to the terms herein.

Additional Administrative Information

Epinephrine Product:   Lot Number:   Expiration:

Signatory Authorization

The undersigned certifies that the information provided on this form is true and correct to the best of their knowledge and that they understand and accept the terms of this Epinephrine Resolution.

If signing as legal guardian or authorized representative, indicate relationship:

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