Medication Handover Checklist Form
Use this form to document the handover of medications between responsible parties. Complete all checklist items and record essential handover details.
Name of person handing over medication
*
First Name
Last Name
Name of person receiving medication
*
First Name
Last Name
Date and time of handover
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Medication name(s)
*
Medication quantity/count
*
Current status/condition of medication (check all that apply)
*
Sealed packaging
Unopened
Opened (partial use)
Expired
Damaged packaging
Other
Checklist: Confirm each step is completed
*
Medication(s) counted and verified
Medication(s) match handover documentation
Packaging checked for integrity
Expiry date(s) checked
Both parties reviewed and agreed on handover details
Exceptions or issues noted during handover
Additional comments or instructions
Signature of person handing over
*
Signature of person receiving
*
Submit Handover Record
Submit Handover Record
Should be Empty: