Antiemetic Medication Pre-Administration Assessment Checklist
Complete this assessment to ensure all pre-administration checks are performed before administering antiemetic medication.
Patient or Encounter Identifier
*
Antiemetic Medication to be Administered
*
Please Select
Ondansetron
Metoclopramide
Prochlorperazine
Promethazine
Other
Time Since Last Antiemetic Dose
*
Please Select
No previous dose
Less than 2 hours
2–4 hours
4–8 hours
More than 8 hours
Current Nausea or Vomiting Symptoms
*
No symptoms
Mild nausea
Moderate nausea
Severe nausea or vomiting
Known Allergies or Prior Adverse Reactions to Antiemetics
*
No known allergies or adverse reactions
Yes – specify below
If yes, describe allergy or adverse reaction
Contraindication/Safety Screening (check all that apply)
*
No contraindications identified
Prolonged QT interval
Known drug interaction
Hypersensitivity to medication
Other safety concern (specify below)
If other safety concern, please specify
Pre-administration Vitals or Key Symptoms (check all assessed)
*
Blood pressure within normal range
Heart rate within normal range
Level of consciousness appropriate
No respiratory distress
Other (specify below)
Is the antiemetic medication due and available for administration?
*
Yes
No
Clinician Readiness Decision
*
Ready to proceed with administration
Not ready – further review required
Additional Notes (optional)
Submit Assessment
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