Medication Dose Audit Log Form
Log and review key details for each medication dose administered. Please complete all fields accurately for audit purposes.
Date and time of administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Medication name
*
Dose administered
*
Unit of dose
*
Please Select
mg
mL
g
units
tablet(s)
capsule(s)
Other
Route of administration
*
Please Select
Oral
IV
IM
Subcutaneous
Topical
Inhalation
Other
Reason for administration
*
Please Select
Scheduled dose
PRN (as needed)
Stat/emergency
Dose adjustment
Other
Person administering medication (initials or staff ID)
*
Person verifying administration (initials or staff ID)
Lot number or batch (if applicable)
Additional notes or observations
Submit Log Entry
Should be Empty: