Medication Administration Competency Checklist Form
Use this form to assess and document medication administration competency for staff or trainees.
Respondent and Role Information
Staff Member / Trainee Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Department / Unit
*
Please Select
Medical/Surgical
Emergency
Intensive Care
Pediatrics
Maternity
Outpatient
Pharmacy
Other
Facility / Location
*
Assessor / Evaluator Name
*
First Name
Middle Name
Last Name
Assessor / Evaluator Title
Date of Competency Assessment
*
-
Month
-
Day
Year
Date
Employment Status / Shift
Please Select
Full-time
Part-time
Per diem
Day shift
Evening shift
Night shift
Other
Medication Administration Competency Checklist
Training, Practice, and Outcome
Prior medication administration training completed?
*
Yes
No
Training type
Please Select
Orientation
Annual refresher
Supervised practice
Simulation
Other
Date of last refresher or supervised practice
-
Month
-
Day
Year
Date
Observed successful administrations
Demonstrated competency independently?
*
Yes
No
Overall result
*
Please Select
Competent
Needs retraining
Not yet competent
Assessor comments
Required re-assessment date
-
Month
-
Day
Year
Date
Submit
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