IV Medication Competency Evaluation Form
Evaluate competency in IV medication administration using this structured assessment form.
Evaluator's Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Role of Evaluatee
*
Please Select
Registered Nurse
Licensed Practical Nurse
Nursing Student
Other
Knowledge of IV Medication Protocols
*
1
2
3
4
5
Ability to Identify and Prepare IV Medications
*
1
2
3
4
5
Aseptic Technique During IV Medication Administration
*
1
2
3
4
5
Select the correct steps for IV medication administration:
*
Verify medication order
Check patient allergies
Use non-sterile gloves only
Monitor patient during administration
Document administration
Other
How confident is the evaluatee in responding to IV medication complications?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Assessment of IV Medication Administration Skills
*
Rows
Needs Improvement
Competent
Exceeds Expectations
Preparation and Verification
1
2
3
Patient Identification
4
5
6
Aseptic Technique
7
8
9
IV Site Assessment
10
11
12
Post-Administration Monitoring
13
14
15
Evaluator Comments
Submit Evaluation
Should be Empty: