Naloxone Administration Report Template
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Naloxone Administration Report Template
Scenario: Help at the community center
At 2:10 p.m., Harper finds an adult unresponsive in a hallway. The person is breathing very slowly and has bluish lips. Harper asks someone nearby to call 911 and get an AED and naloxone. Following the naloxone package directions, Harper gives one dose of nasal naloxone at 2:13 p.m. Harper stays with the person, watches their breathing, and follows the 911 dispatcher’s directions. At 2:18 p.m., the person begins responding but seems confused. EMS arrives at 2:22 p.m. Harper tells the responders what happened and when naloxone was given.
Record the incident
Use only details given in the scenario. Write “not stated” if information is missing. Do not guess or add identifying information.
- Unresponsive
- Very slow breathing
- Bluish lips
- A rash
- A broken arm
Document the response
Make the timeline easy for another responder to follow.
Clear, safe reporting
Think about what a helpful report includes—and what it should leave out.
- “At 2:10 p.m., I found an adult unresponsive and breathing very slowly.”
- “The person was definitely using drugs and was being careless.”
3 printable pages
Page 1
Page 2
Page 3
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