Name:

Room Number:

Date of Birth:

Resident Identification and Verification

Confirm resident's identity using two identifiers (e.g., name and date of birth).

• Yes

• No

Cross-reference identification with the resident's medical record.

• Yes

• No

Medication Order Verification

Review physician's medication order.

• Yes

• No

Verify medication name, dosage, route, frequency, and administration time.

• Yes

• No

Check for any allergies or contraindications.

• Yes

• No

Medication Preparation

Gather necessary supplies.

• Yes

• No

Prepare medication according to the prescription and facility protocols.

• Yes

• No

Label medication if required by facility policy.

• Yes

• No

Administration Process

Administer medication at the scheduled time.

• Yes

• No

Verify the resident's willingness and ability to take medication.

• Yes

• No

Administer medication using the correct route (e.g., oral, topical, injectable).

• Yes

• No

Document administration details (e.g., date, time, dosage, route) on the resident's medication administration record (MAR).

• Yes

• No

Monitoring and Observation

Monitor resident for any adverse reactions or side effects.

• Yes

• No

Assess vital signs if necessary.

• Yes

• No

Document any observed reactions or changes in the resident's condition.

• Yes

• No

Resident Education and Counseling

Provide information to the resident and/or family regarding medication purpose, dosage, and potential side effects.

• Yes

• No

Offer counseling on medication adherence and management.

• Yes

• No

Documentation and Communication

Record medication administration details accurately on the MAR.

• Yes

• No

Communicate any concerns or changes in medication status to the healthcare team.

• Yes

• No

Document any missed doses or medication refusals.

• Yes

• No

Follow-Up and Quality Assurance

Conduct regular audits to ensure compliance with medication administration protocols.

• Yes

• No

Review incident reports and address any medication errors promptly.

• Yes

• No

Implement corrective actions as needed to improve medication administration processes.

• Yes

• No

Disposal of Medications

Dispose of expired or unused medications according to facility policy and regulatory guidelines.

• Yes

• No

Document medication disposal appropriately.

• Yes

• No

Training and Competency Assessment

Provide ongoing training and education to nursing staff on medication administration procedures.

• Yes

• No

Conduct competency assessments to ensure staff proficiency in medication administration.

• Yes

• No