Medication Administration Competency Assessment
Use this form to document medication administration competency, observation results, knowledge checks, remediation needs, and assessor notes.
Assessor and Assessment Details
Assessor Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role or Department
Please Select
Nursing
Pharmacy
Physician
Allied Health
Other
Medication Administration Knowledge Check
Confidence in medication administration competency
*
Needs support
1
2
3
4
Highly confident
5
1 is Needs support, 5 is Highly confident
Preferred medication administration step sequence
*
Verify order
Prepare medication
Identify patient
Administer medication
Document administration
Observe response
The 5 rights of medication administration
*
Right patient
Right medication
Right dose
Right time
Right route
Checks completed before administering medication
*
When to pause and escalate concerns
*
If the medication order is unclear or incomplete
If the patient identity cannot be confirmed
If allergy, vital sign, or parameter checks are outside range
If the medication packaging or label does not match the order
If there are any concerns about the situation
All of the above
Remediation and Sign-off
Remediation / refresher training topics
Hand hygiene
Medication rights review
Dose calculation practice
Documentation standards
Aseptic technique
Infection prevention
Observation of administration technique
Other
Final comments / observations
Completion acknowledgment
*
I confirm the remediation or refresher training has been completed and the assessment is ready for sign-off
Submit Assessment
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