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Licensing & Certification Program General Acute Care Hospital Relicensing Survey
MEDICATION PASS WORKSHEET Provider Number Surveyor Name Date/Time Location/Staff
Instructions: 1. Observe medication administration by facility staff. 2. Record observation of each medication administered including medications that are held. 3. Reconcile record with physician orders.
Identifier Pour Pass Notes Drug Name , Strength, Discrepancies Between Observation
Patient’s Name/Room # Route/Techniques of Administration Form and Quantity and Physician Orders, P&P/SOP
July 2016 Page 1 of 2