EVALUATION FOR SELF-ADMINISTRATION OF MEDICATION …

EVALUATION FOR SELF-ADMINISTRATION OF MEDICATION

Resident Name:

Evaluation Type: Initial Routine Other

Instructions: Review with the resident the "interview" content below, noting answers/observations as applicable. Record details

if the resident is unable to respond appropriately or to include other information/sources related to this evaluation.

INTERVIEW the resident about the following:

Yes No

COMMENTS

1) Does the resident record contain a current MD order to

self-administer all or part of their medications/treatments?

2) Will the resident be self-administering ALL medications

(prescription and OTC) and treatments? ( If not, list in "comments"

ONLY the medications/treatments that WILL be self- administered.

Indicate " Partial self-administration" on the service plan, with

reference to MAR for which will be self administered.)

3) Does resident have any medical/physical condition that might

affect ability to self- administer medications?

[circle all that apply:] dementia limited range of motion

impaired vision other/specify:

4) Can resident identify the purpose of each medication (s)

by name or sight?

[Ask: How do you tell your medications apart?]

5) Does the resident know the purpose of each medication?

[ Ask: Can you tell me what each medication is for?}

6) Can resident properly describe or demonstrate the correct

amount and time for each medication dosage?

[Ask: How much and what time of day do you take each of your

medications?]

7) Can resident safely and consistently store the medication (s) in

their apartment, if the room is shared with a spouse/resident who

cannot self-administer?

[Request demonstration: Show me where you store your

medications? What is your routine when you finish taking them?]

8) Can resident describe understanding of the need for

communicating with his/her doctor for questions or concerns

about the medications, and about taking other

medications not prescribed ( including herbal, nutritional or other

supplements and OTC drugs)?

[Ask: How often do you talk with your doctor about your

medications? What do you do if you think you are having a

reaction to one of your medications?]

Determination: Based on this interview, is resident

capable to manage/control medications safely and consistently

AND communicating effectively with their doctor or other presciber?

NOTE: Whenever a resident has been able to self-administer in the past but indicates during this evaluation

that self-administration may no longer be safe, the interviewer must notify appropriate staff in the

community, the resident's responsible party, and the physician/prescriber.

Evaluator signature:

Date:

[Keep the most current completed evaluation form behind the resident's current service plan;

move any prior form to the resident's health record (under the tab for "assessments").]

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