MEDICATION ADMINISTRATION AND HEALTH-RELATED ACTIVITIES SKILLS CHECKLIST

*To be completed for every employee (who administers meds) annually

Also needs to be completed before an employee can administer a route (nasal, ear, etc) in which he/she has not been previously trained (checklist completed for that route).

Process


1. Employee attends and passes the Medication Administration Certification class or the Recertification Class.

2. At the home, the employee will do skills checks with the approved person (Director/Manager/Coordinator or other person approved by the nurse). Both parties will sign and date the forms. For renewals, this can be done up to 6 months prior to renewal class.

3. This form is completed. That means the employee is observed:

a. Correctly passing oral medication to (at Ieast one person)

b. Correctly administering all additional routes of medication that occur at that location (i.e. nebulizer, eye drops, etc).

c. Correctly performing any health-related activities that occur at that location (i.e. checking blood pressure).

d. Signing and dating the Master Signature Sheet

e. Initialing the MAR

4. Nursing will be automatically notified that skills checks are complete for this staff.

NOTE: If new skills are used for a client at any time, return to this page and complete the check list for the new skill for all staff.***


Page 1

GENERAL Medication Administration Skills Checklist

Note: All boxes on this page must be checked in order to proceed to the skill checks.

(To be used at the beginning of EACH skill check) *
Trainee Name*
My initials signify that I received this training
Use your mouse or finger to draw your signature above
Date*
Use your mouse or finger to draw your signature above

Page 2

Skill Checklist for Administering Medication by Mouth (Oral)

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following :
6. The first check of the MAR to label:
7. The second check of the MAR to label:
10. The third check (done for each medication after it is placed in the cup):
Trainee Name
Date
Instructor Name

Page 3

Skill Checklist for Administering Sublingual or Buccal Medication

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following :
6. The first check of the MAR to label:
7. The second check of the MAR to label:
10. The third check (done for each medication after it is placed in the cup):

If mucous membrane is intact (without sores or irritation):

A. For sublingual medication administration:
B. For buccal medication administration:
Trainee Name
Date
Instructor Name

Page 4

Skill Checklist for Administering Medications to Skin

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following :
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before application of medication to skin):
Trainee Name
Date
Instructor Name

Page 5

Skill Checklist for Administering OTC Topical Medications for Musculoskeletal Comfort

Purchasing/choosing the OTC topical medication for musculoskeletal comfort:
3. Identify the following from the product label:

Use of the OTC topical medication for musculoskeletal comfort:

1. Before application of the medication, check to determine if the medication is needed/wanted by the person. Verify:
Trainee Name
Date
Instructor Name

Page 6

Skill Checklist for Administering Transdermal Medication

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before application of medication to skin):
Trainee name:
Date/Time
Instructor Name

Page 7

Skill Checklist for Administering Eye (Ophthalmic) Medications

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before putting medication in eye(s)):
Special Note: Always hold eye dropper level with the eye. Do not point the dropper toward the eye. Never let the dropper touch the eye.
To prevent contamination, do not touch the end of the applicator tip on any part of the eye.
Trainee Name
Date
Instructor Name

Page 8

Skill Checklist for Administering Ear (Otic) Medications

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before putting medication in ear(s)):
Trainee name:
Date:
Instructor Name:

Page 9

Skill Checklist for Administering Nose (Nasal) Medications

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before putting medication in nose):
Trainee Name
Date
Instructor Name

Page 10

Skill Checklist for Administering Nebulizer Treatment

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
The third check of the MAR is done before placing the pre-measured ampule dose of medication into the nebulizer’s dispensing chamber (before use of nebulizer):
Trainee Name
Date
Instructor Name

Page 11

Skill Checklist for Administering Metered Dose Inhalers

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
13. The third check of the MAR is done before preparing the canister/inhaler (before use of inhaler):
15. (A) If using a spacer:
15. (B) If not using a spacer:
15. (C) If you are using a dry powder inhaler:
Trainee name:
Date:
Instructor Name:

Page 12

Skill Checklist for Administering Oxygen (O2)

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
4. The first check of the MAR. Read the MAR for the oxygen order to assure the 5 Rights (I M DR T):

If any part of the order is not clear and the person’s pulse oximeter reading is 92 or below, proceed with administering oxygen at a flow rate of 2 liters per minute and contact a healthcare professional IMMEDIATELY.

7. The second check of the MAR. Read the MAR for the oxygen order to assure the 5 Rights (I M DR T):
16. The third check of the MAR. Read the MAR for the oxygen order to assure the correct amount of oxygen is being administered according to the 5 Rights (I M DR T):
Trainee name:
Date:
Instructor Name:

Page 13

Skill Checklist for Administering Diastat®

(Locating the Diastat®, checking the expiration date and doing the 3 checks on the MAR were done at the beginning of the shift to be prepared to administer quickly in this situation)

Trainee Name
Date
Instructor Name

Page 14

Skills Checklist for Administering Nasal Versed® (Midazolam)

Locating the Nasal Versed®, checking the expiration date and doing the 3 checks on the

MAR were done at the beginning of the shift to be prepared to administer quickly in this

situation.

**Call 911 if:

  • The person is turning blue or is having problems breathing
  • The person remains unconscious more than 20 minutes after the seizure ends
  • The seizure is different from previous seizures
  • The person sustained a head injury or other life-threatening injury during seizure
  • The seizure does not stop within the time frame specified by the healthcare professional
Trainee Name
Date
Instructor Name

Page 15

VALTOCO® (diazepam nasal spray) Skills Checklist

Trainee Name
Date
InstructorName

Page 16

Skill Checklist for Administering Vaginal Medications

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The second check of the MAR to label:
9. The third check (done before inserting the suppository):
Trainee name:
Date:
Instructor Name:

Page 17

Skill Checklist for Administering Rectal Suppositories

2. Start at the beginning of the medication administration record (MAR) and review, checking for the following:
6. The first check of the MAR to label:
7. The secondcheck of the MAR to label:
9. The third check (done before inserting the suppository):
Trainee Name
Date
Instructor Name

Page 18

Skill Checklist for Taking a Temperature

Trainee Name
Date
Instructor Name

Skill Checklist for taking a Pulse

Trainee Name
Date
Instructor Name

Page 19

Skill Checklist for Counting Respiration

4. Document the time, and date the vital signs were taken:
Trainee Name
Date
Instructor Name

Steps for Taking a Blood Pressure (with an arm cuff)

If possible, always use an automated cuff. Get additional training and practice if you

need to use a manual cuff.

Trainee Name
Date
Instructor Name

Page 20

Skill Checklist for Application of a Clean Dressing When No Assessment is Required

15. Document and report the following observations to a healthcare professional:
Trainee Name
Date
Instructor Name

Page 21

Skill Checklist for Application of Compression Hose

Trainee name:
Date:
Instructor Name:

Page 22

Skill Checklist for Using a Glucometer to Monitor Blood Sugar

Trainee name:
Date:
Instructor Name:

Page 23

Skill Checklist for Oral Suctioning

If the person starts to cough or gag, take the catheter out until the person recovers before continuing.


NEVER SUCTION FOR LONGER THAN 15 SECONDS AT ONE TIME

Trainee Name
Date
Instructor Name

Page 24

Skill Checklist for Using a Pulse Oximeter (Pulse Oximetry)

Trainee name:
Date:
Instructor Name:

Page 25

Skill Checklist for Use of CPAP/BiPAP Machine

Trainiee Name
Date
Instructor Name

Page 26

Skill Checklist for Emptying and Replacing a Colostomy Bag

Personnel must receive training specific to the person, their supplies, equipment and person-specific procedure before emptying or changing a person’s ostomy bag.

Emptying a Colostomy Bag

Replacing a Colostomy Bag

Confirm change date on MAR/TAR; perform steps 1-6 above, then
Trainee name:
Date:
Instructor Name:

Page 27

Skill Checklist for Basic Measuring of Bodily Intake

Skill Checklist for Basic Measuring of Bodily Output

Trainee Name
Date
Instructor Name

Page 28

Steps for Collection of Clean Catch (Mid-Stream) Urine Sample

Trainee Name
Date
Instructor Name

Page 29

Skill Checklist for External Urinary Catheter Care

Trainee name:
Date:
Instructor Name:

Page 30

Skill Checklist for Emptying the Urine Collection Bag

Trainee name:
Date:
Instructor Name:

Page 31

Skill Checklist for Use of Cough Assist Insufflator - Exsufflator:

DO NOT EVER ATTEMPT TO USE THIS DEVICE WITHOUT DIRECT TRAINING WITH THE PERSON WHO WILL BE GETTING THIS TREATMENT AND HAVING YOUR SKILLS VERIFIED BY A PERSON WHO KNOWS HOW TO DO THE TREATMENT

Trainee Name
Date
Instructor Name

Page 32

Skill Checklist for Using a Percussion Vest

Please select all skills checklists that you filled out on this form*
Trainee name:
Date:
Instructor Name:

Page 33

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