Medication Observation Checklists Submission

Before you hit Fax or Send, did you do the following?

� Make a copy of your 3 checklists (front and back) to keep for your records.

� Are all 3 forms completed in their entirety?a. Has every line or box been filled out?b. Has every task been checked off with yes?

i. If a particular task does not apply to the individual or the medication(s) they are taking at thattime (ex- the individual is not taking a liquid medication at this time), the block must be filled inwith NA (Not Applicable)

c. Was the final observation completed by the Program Manager or Program Nurse?d. Is the Vital Sign Check Off completed on the 3rd observation by the Program Manager or Program Nurse?

� When submitting your checklists via fax or email- make sure you send the front AND back of each observation sheet.

DEADLINE:

ALL 3 Medication Observation Checklist Forms MUST be completed within 30 DAYS after passing the Med Management course.

Please submit Medication Pass Observations to: Jessica Compton Training Assistant jcompton@comres.org training@comres.org Tel: 703-842-2316 Fax: 703-842-2398

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

MEDICATION ADMINISTRATION

EMPLOYEE OBSERVATION CHECKLIST

To be completed by the Employee:

EMPLOYEE (passer) NAME:

PROGRAM & OBSERVER:

New Passer Guidelines: 1. Deadline: All Three Medication Observation Checklists must be completed within 30 days after passing the Medication

Management Class. (Your observations are due ____________)

2. Independent medication passing may NOT occur until ALL 3 Observation Checklists are completed.

3. Each Med Observation Form must consist of 10 medications passed (complete box below).

4. Observation #1: Can be completed by any Med Aid with a current certification.

5. Observation #2: Can be completed by any Med Aid with a current certification.

6. Observation #3: MUST be completed by the Program Manager, or the Program Nurse, to include the Vital Signs.

Random/Med Error Guidelines: 1. All Medication Aides are required to be observed passing medications annually prior to their Performance Evaluation.

2. Random Checks of Medication Passes will be completed by a Program Manager or a Program Nurse, and can be

completed at any time.

3. Any Medication Aid who does not complete a med pass satisfactorily MUST receive on-the-spot documented training

and a new med pass must be completed successfully before medications can be passed independently again.

4. A Program Manager or a Program Nurse may suspend medication passing privileges at any time.

Date & time each observed medication is passed:

1.

Date:__________ Time:__________

2.

Date:__________ Time:__________

3.

Date:__________ Time:__________

4.

Date:__________ Time:__________

5.

Date:__________ Time:__________

6.

Date:__________ Time:__________

7.

Date:__________ Time:__________

8.

Date:__________ Time:__________

9.

Date:__________ Time:__________

10.

Date:__________ Time:__________

Yes No

1. Starts med pass on time with the observer.

2. Gathers needed supplies before med pass (cups, nutritional supplements, apple sauce, pudding, spoons, etc.)

3. Work area is clean and free of clutter.

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

Yes No

4. MAR completed as trained.

5. Washes hands before passing meds.

6. Washes hands any time contamination occurs, able to define what would be considered contamination.

7. Prepares medication for one person at a time.

8. Selects the appropriate medications for time being given.

9. Verifies has correct individual by picture in MAR.

11. Compares medication label to MAR three times for each med given.

12. Punches medications into medication cup without contaminating them.

13. Places first initial in the appropriate box on the MAR.

14. Liquid medications are shaken before being poured and are poured at eye level.

15. Liquid medications are poured away from label to avoid contamination.

16. If the medication is a controlled substance, special documentation procedures are followed.

17. Locks medication cabinet prior to giving the individual his/her medications.

18. Medications are given to the individual with appropriate fluid, applesauce, or pudding.

19. Stays with the individual until he/she has swallowed the medication.

20. Places second initial in the appropriate box on the MAR.

21. After administering medications, washes hands after each individual.

22. Proceeds in the same manner for the next individual.

23. When all medications are administered, disposes of unused food or liquids, restocks the cart with supplies, and cleans and locks the cabinet.

Record Vital Signs (Observation #3 Only): BP________ T ________ P ________ R ________

OBSERVATION COMPLETED BY: (Print)_________________________(Sign)_________________________

(Title)_________________________(Date)_________________________

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

MEDICATION ADMINISTRATION

EMPLOYEE OBSERVATION CHECKLIST

To be completed by the Employee:

EMPLOYEE (passer) NAME:

PROGRAM & OBSERVER:

New Passer Guidelines: 1. Deadline: All Three Medication Observation Checklists must be completed within 30 days after passing the Medication

Management Class. (Your observations are due ____________)

2. Independent medication passing may NOT occur until ALL 3 Observation Checklists are completed.

3. Each Med Observation Form must consist of 10 medications passed (complete box below).

4. Observation #1: Can be completed by any Med Aid with a current certification.

5. Observation #2: Can be completed by any Med Aid with a current certification.

6. Observation #3: MUST be completed by the Program Manager, or the Program Nurse, to include the Vital Signs.

Random/Med Error Guidelines: 1. All Medication Aides are required to be observed passing medications annually prior to their Performance Evaluation.

2. Random Checks of Medication Passes will be completed by a Program Manager or a Program Nurse, and can be

completed at any time.

3. Any Medication Aid who does not complete a med pass satisfactorily MUST receive on-the-spot documented training

and a new med pass must be completed successfully before medications can be passed independently again.

4. A Program Manager or a Program Nurse may suspend medication passing privileges at any time.

Date & time each observed medication is passed:

1.

Date:__________ Time:__________

2.

Date:__________ Time:__________

3.

Date:__________ Time:__________

4.

Date:__________ Time:__________

5.

Date:__________ Time:__________

6.

Date:__________ Time:__________

7.

Date:__________ Time:__________

8.

Date:__________ Time:__________

9.

Date:__________ Time:__________

10.

Date:__________ Time:__________

Yes No

1. Starts med pass on time with the observer.

2. Gathers needed supplies before med pass (cups, nutritional supplements, apple sauce, pudding, spoons, etc.)

3. Work area is clean and free of clutter.

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

Yes No

4. MAR completed as trained.

5. Washes hands before passing meds.

6. Washes hands any time contamination occurs, able to define what would be considered contamination.

7. Prepares medication for one person at a time.

8. Selects the appropriate medications for time being given.

9. Verifies has correct individual by picture in MAR.

11. Compares medication label to MAR three times for each med given.

12. Punches medications into medication cup without contaminating them.

13. Places first initial in the appropriate box on the MAR.

14. Liquid medications are shaken before being poured and are poured at eye level.

15. Liquid medications are poured away from label to avoid contamination.

16. If the medication is a controlled substance, special documentation procedures are followed.

17. Locks medication cabinet prior to giving the individual his/her medications.

18. Medications are given to the individual with appropriate fluid, applesauce, or pudding.

19. Stays with the individual until he/she has swallowed the medication.

20. Places second initial in the appropriate box on the MAR.

21. After administering medications, washes hands after each individual.

22. Proceeds in the same manner for the next individual.

23. When all medications are administered, disposes of unused food or liquids, restocks the cart with supplies, and cleans and locks the cabinet.

Record Vital Signs (Observation #3 Only): BP________ T ________ P ________ R ________

OBSERVATION COMPLETED BY: (Print)_________________________(Sign)_________________________

(Title)_________________________(Date)_________________________

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

MEDICATION ADMINISTRATION

EMPLOYEE OBSERVATION CHECKLIST

To be completed by the Employee:

EMPLOYEE (passer) NAME:

PROGRAM & OBSERVER:

New Passer Guidelines: 1. Deadline: All Three Medication Observation Checklists must be completed within 30 days after passing the Medication

Management Class. (Your observations are due ____________)

2. Independent medication passing may NOT occur until ALL 3 Observation Checklists are completed.

3. Each Med Observation Form must consist of 10 medications passed (complete box below).

4. Observation #1: Can be completed by any Med Aid with a current certification.

5. Observation #2: Can be completed by any Med Aid with a current certification.

6. Observation #3: MUST be completed by the Program Manager, or the Program Nurse, to include the Vital Signs.

Random/Med Error Guidelines: 1. All Medication Aides are required to be observed passing medications annually prior to their Performance Evaluation.

2. Random Checks of Medication Passes will be completed by a Program Manager or a Program Nurse, and can be

completed at any time.

3. Any Medication Aid who does not complete a med pass satisfactorily MUST receive on-the-spot documented training

and a new med pass must be completed successfully before medications can be passed independently again.

4. A Program Manager or a Program Nurse may suspend medication passing privileges at any time.

Date & time each observed medication is passed:

1.

Date:__________ Time:__________

2.

Date:__________ Time:__________

3.

Date:__________ Time:__________

4.

Date:__________ Time:__________

5.

Date:__________ Time:__________

6.

Date:__________ Time:__________

7.

Date:__________ Time:__________

8.

Date:__________ Time:__________

9.

Date:__________ Time:__________

10.

Date:__________ Time:__________

Yes No

1. Starts med pass on time with the observer.

2. Gathers needed supplies before med pass (cups, nutritional supplements, apple sauce, pudding, spoons, etc.)

3. Work area is clean and free of clutter.

CLI-MM-03

New Passer: Observation #: 1 2 3 (circle one)

Med Error Observation:

Random Observation:

Yes No

4. MAR completed as trained.

5. Washes hands before passing meds.

6. Washes hands any time contamination occurs, able to define what would be considered contamination.

7. Prepares medication for one person at a time.

8. Selects the appropriate medications for time being given.

9. Verifies has correct individual by picture in MAR.

11. Compares medication label to MAR three times for each med given.

12. Punches medications into medication cup without contaminating them.

13. Places first initial in the appropriate box on the MAR.

14. Liquid medications are shaken before being poured and are poured at eye level.

15. Liquid medications are poured away from label to avoid contamination.

16. If the medication is a controlled substance, special documentation procedures are followed.

17. Locks medication cabinet prior to giving the individual his/her medications.

18. Medications are given to the individual with appropriate fluid, applesauce, or pudding.

19. Stays with the individual until he/she has swallowed the medication.

20. Places second initial in the appropriate box on the MAR.

21. After administering medications, washes hands after each individual.

22. Proceeds in the same manner for the next individual.

23. When all medications are administered, disposes of unused food or liquids, restocks the cart with supplies, and cleans and locks the cabinet.

Record Vital Signs (Observation #3 Only): BP________ T ________ P ________ R ________

OBSERVATION COMPLETED BY: (Print)_________________________(Sign)_________________________

(Title)_________________________(Date)_________________________