INDEPENDENT WITH MEDICATION SELF-ADMINISTRATION
INDEPENDENT WITH MEDICATION SELF-ADMINISTRATION
EVALUATION FORM
RESIDENT NAME: APT #:
This form is to be completed when a resident would prefer to manage his/her own medications; re-evaluate using this form following changes in condition as well as during a full assessment.
MEDICATION ORDERING AND DELIVERY
← Resident/family orders medications
← Facility staff orders medications
MEDICATION STORAGE
Store in a safe location? ( Yes ( No
Away from other resident access? ( Yes ( No
SELF-ADMINISTRATION OF MEDICATIONS
Able to self-administer accurately? ( Yes ( No
Understands medication use(s)? ( Yes ( No
Medications taken at the correct time at the right dose? ( Yes ( No
After evaluation, resident is ( able ( not able to safely self-administer medications.
Comments/notes:
Signature of qualified assessor Date
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