Distributing,
Documenting &
Storing Naloxone

BCCDC, VCH and your college or professional organization all have practice standards that must be followed,

with respect to dispensing/distributing, documenting and storing Naloxone.

1

Training

When distributing: BCCDC requires that anyone distributing Naloxone must have completed appropriate training, such as this course. BCCDC also requires that, whenever kits are distributed, this distribution record be completed and submitted to them.

For the client: It is recommended to teach the client from the THN: Participant Knowledge Checklist

2

Documentation

VCH staff should document in the client's record when they distribute a THN kit.  The purpose of this is to communicate the care given and to meet professional and legal standards. It is not necessary to document in the client's record in the following 2 scenarios: 1) when the staff does not have access to the client's health record and, 2) when the staff member is conducting a large group Naloxone training for participants who are non-VCH clients. *Reminder* in all situations, the BCCDC THN Distribution Record still needs to be filled out for each kit distributed in all types of trainings.

BCCDC THN Distribution Record Progress Note

(eg. casenote or encounter note)

Medication Record
Nurses (RN, RPN, LPN) X X X
Allied Health & Unregulated Care Providers

Who have access to the client health record

X X
Unregulated Care Providers/Staff

Who do not have access to the client health record

X

3

Storage

Naloxone vials should be checked regularly for the expiry date and stored at room temperature in the original packaging until used.

Image of spreadsheet 2

I work in a facility that distributes Naloxone Kits and must adhere to VCH documentation standards.
What do I do next?

Record the following information in the client record, as per your site’s policy. 

  • client name, date of birth, gender and, when available, allergies and adverse reactions
  • date dispensed
  • name, strength, dosage of medication and quantity dispensed
  • directions given to client
  • signature and title of person dispensing the medication
  • If no client-specific medical record exists, or if you do not have access to electronic medical records, complete the Naloxone distribution record and keep it in a THN binder at your site.

A mother comes to your site asking to receive a THN kit and training. Her 18 year-old daughter occasionally stays with her and has a history of illicit stimulant use. Is this mother eligible for a kit, and if so, why?

Yes she is eligible for a kit. According to the BCCDC THN program, kits are available “for people who are at risk of an opioid overdose and people who are likely to witness and respond to an overdose.” In this case, her daughter is at risk for an overdose based on her illicit substance use and the potential risk for all drugs (including stimulants) to be contaminated with fentanyl or other toxic analogues.

Hmm... Actually, this is an example of when you might see an amount in your budget for Physician Compensation.

You are dispensing a THN kit to someone who declines to be entered into your electronic medical records system. How would you document this interaction and kit dispensing?

Although this person does not want to be entered into the computer system, we still have an obligation to document dispensing the kit. All sites need to keep a THN binder on-site to house paper documentation for those clients who do not want to be entered into our electronic medical records system. The following forms should be completed in hard copy and kept in this binder: Form 1

Hmm... Actually, this is an example of when you might see an amount in your budget for Physician Compensation.

  • Store Naloxone at room temperature (15-30 degrees Celsius) and away from direct light
  • Educate individuals receiving kits that they should periodically check the expiry dates on the ampules of Naloxone, keep Naloxone in the same location, and let others know where it is, in case of emergency
  • Follow BCCDC, VCH and college practice standards regarding dispensing, documenting and storing Naloxone