Self-Administration of Medication Assessment

Interdisciplinary assessment of a resident's cognitive and physical ability to safely keep, access, and self-administer medications in their room.

Assessment Details

• Resident identified and assessment date documented
• Assessment completed by interdisciplinary team member(s)
• Reason for assessment documented
• Current medication list reviewed against resident's report

Cognitive Ability and Understanding

• Resident is oriented to person, place, and situation sufficiently to manage medications
• Resident can state medication names or recognize medications by appearance
• Resident can explain purpose and schedule for each medication
• Resident demonstrates understanding of missed-dose or refusal process
• Resident demonstrates safe judgment regarding sharing, hoarding, or duplicating medications

Physical Ability and Medication Handling

• Resident can read medication labels or has an approved accommodation to do so
• Resident can open medication containers or blister packs safely
• Resident can manipulate pills, inhalers, drops, or other prescribed dosage forms as applicable
• Resident can follow the prescribed route of administration without assistance

Medication Storage and Room Safety

• Medication storage area in resident room is secure and inaccessible to unauthorized persons
• Medications are stored separately from food, chemicals, and other prohibited items
• Medications requiring refrigeration are stored at proper temperature
• Controlled substances, if applicable, are managed according to facility policy and state requirements

Self-Administration Outcome and Plan

• Resident is approved to self-administer medications independently
• If not fully independent, level of assistance is clearly documented
• Resident and responsible party informed of assessment outcome
• Follow-up plan, restrictions, or retraining documented