Medication Nursing Assessment Form
Complete this form to assess patient medication administration, adherence, side effects, and related nursing observations.
Medication Name
*
Dosage and Frequency
*
Route of Administration
*
Please Select
Oral
Intravenous (IV)
Intramuscular (IM)
Subcutaneous
Topical
Other
Medication Adherence
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Observed Side Effects
Nausea
Dizziness
Rash
Fatigue
Other
Severity of Side Effects
1
2
3
4
5
Known Allergies to Medications
*
Penicillin
Sulfa drugs
Aspirin
Latex
No known allergies
Other
Ability to Self-Administer Medication
*
Independent
Needs Assistance
Dependent
Nursing Observations (Select and rate each area)
*
Rows
Not Observed
Mild
Moderate
Severe
Swallowing Difficulty
1
2
3
4
Cognitive Alertness
5
6
7
8
Motor Skills
9
10
11
12
Behavioral Changes
13
14
15
16
Additional Nursing Notes
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Assessment
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