DEPARTMENT OF MENTAL RETARDATION
CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES
SELF-ADMINISTRATION Of MEDICATION ASSESSMENT TOOL
|Name: |Date: |
| | |
|Address: |Indicate: Baseline Assessment Re-Assessment |
|Method of Assessment: Indicate all that apply |Observation |Interview with individual |
| |Interview with staff |Interview with family |
|Skill statement: Individual........ |
| |Yes |No |
|1. Knows names of all the medications s/he takes. If “no” check one|Knows names of some of the medications taken | | |
|of the following: |Knows none of the names of meds taken | | |
|2. Reads medication label | | |
|3. Identifies medications: |Color |Sight |Quantity needed | | |
|check all that apply for “yes” answer | | |(can count to at least 6) | | |
|4. Knows the reason each medication is |Knows the reason for some of the meds taken | | |
|taken If “no” check one of the following: |Does not know the reason for any meds taken | | |
|5. Knows major side effects which may occur |Knows some of the potential side effects | | |
|for all medications taken. If “no” check one: |Does not know any potential side effects | | |
|6. Knows who to notify when s/he notices/suspects a medication side effect. If “yes” indicate who, when, and how | | |
|7. Notifies appropriate person of new medications and/or changes. If “yes”. Specify | | |
|8. Notifies staff if med is omitted. If yes indicate how: | | |
|9. Can tell time and takes medication by clock time |Digital clock |Standard clock | | |
|10. Takes medications at times associated with an activity (meals, waking hour, bedtime, etc.) | | |
|Takes medication with the aid of a device If yes, indicate type |Pill pod/ cassette |Alarm watch | | |
|of device used: | | | | |
| |Calendar |Timed delivery device (ex. Compumed) | | |
|12. Independently fills reminder device | | |
|13. Needs assistance to fill reminder device. |Verbal prompt |Physical assist | | |
|If” yes” indicate type of assistance and who provides | | | | |
| |Staff support |Nursing support | | |
|14. Takes medications only when prompted by supporting staff | | |
|If “yes” indicate who provides this support: | | |
|15. Independently manages own prescription fills and refills | | |
|16. Manages own prescription fills and refills with staff assistance only | | |
|17. Displays independence in appropriately taking over the counter (OTC) preparations | | |
|18. Needs assistance to take OTC preparations correctly | | |
|19. Has skill in taking OTC preparations | | |
|20. Independently understands “special instructions” when taking medications (take with food; take for 10 days, etc.) | | |
|21. Is physically able to swallow pill(s) and/or liquid(s) without difficulty. | | |
|22. Is physically able to remove pills from bottle or blister pack without dropping. | | |
|23. Is free from physical disabilities which may compromise or prevent self-administration. | | |
|24. Is able to measure and pour liquid medications without spillage. | | |
|25. Is able to self-administer eye medications.* | | |
|26. Is able to self-administer ear medications.* | | |
|27. Is able to self-administer nasal medications.* | | |
|28. Is able to self-administer topical medications.* | | |
|29. Is able to self-administer medications via patch.* | | |
|30. Is able to self-administer inhalant medications.* | | |
|31. Is able to self-administer rectal medications.* | | |
|32. Is able to self-administer vaginal medications.* | | |
|33. Is able to self-administer medications via injections.* | | |
|34. Displays knowledge of need for safe storage of medications away from access by others. | | |
|35. Can safely carry own key to room and/or medication supply. | | |
|36. Has a history of drug and/or alcohol abuse. If “:yes”, specify: | | |
*May indicate “NH” in the drop down or “no” box that represents “No history of exposure to task”
CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES
SELF-ADMINISTRATION OF MEDICATION ASSESSMENT TOOL
Page 2
|Name: |Date: |
|Specific concerns related to the individual’s ability: |
| |
|Specific concerns related to the individual’s environmental support: |
|Assessment Findings: |
| |Individual is capable of independent self-administration for the following medications: |
| | otic | optic / ointment / drops | nasal |
| | inhalant | rectal | patch |
| | topical | injection:( specify) | other: (specify) |
| |Comments: |
| |Individual is capable of independent self-administration with the following supports: |
| | Alarm watch | Pill pod/ cassette | Calendar | Other (specify): |
| | Staff oversight: (specify) | Timed delivery device | Nursing agency oversight: (specify) | |
| | | | | |
| |Comments: |
| |Individual is not capable of independent self-administration for the following reasons: |
| | |
| | |
|Recommendations to be included in support plan: | |
| |
| |
| |
| |
|Assessment completed by: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
|Reviewed and no changes: | |, RN Date: | |
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