Run Field Trip Medication Administration Record and Skills Checklist — Free

Trip and Inspection Details

Field trip name, destination, and date are recorded critical (required)

Student/patient identifier is recorded using approved local policy critical (required)

Medication administration is authorized for off-site use by parent/guardian and prescriber order critical (required)

Yes No N/A

Delegated staff assigned to administer medication are identified critical (required)

Emergency contact and health plan information are available for the trip critical (required)

Yes No N/A

Medication administration schedule for the trip is documented critical (required)

Medication Verification and Transport

Medication label matches the authorized student and order critical (required)

Yes No N/A

Medication name, dose, route, and time match the authorization critical (required)

Yes No N/A

Medication is transported in original container with intact label critical (required)

Yes No N/A

Required storage conditions are maintained during transport critical (required)

Medication is secured and inaccessible to unauthorized persons during transport critical (required)

Yes No N/A

Delegated Staff Competency Checklist

Staff demonstrates knowledge of the five rights of medication administration critical (required)

Yes No N/A

Staff can identify the student, medication, dose, route, and time without prompting critical (required)

Yes No N/A

Staff knows when to withhold medication and escalate concerns critical (required)

Yes No N/A

Staff can describe hand hygiene and PPE expectations before administration critical (required)

Yes No N/A

Staff can describe emergency response steps for adverse reaction or medication error critical (required)

Yes No N/A

Medication Administration Record

Date and exact time medication was administered are recorded critical (required)

Note (optional)

Medication administered matches the authorized dose and route critical (required)

Yes No N/A

Administration site or method is documented when applicable

Student response or observed outcome after administration is documented critical (required)

Any refusal, omission, or medication error is documented and escalated critical (required)

Yes No N/A

Closeout, Signatures, and Corrective Actions

Inspector or supervising nurse signature is completed critical (required)

Delegated staff competency verification is signed and dated critical (required)

Any deficiencies or non-conformances are documented with corrective actions critical (required)

Medication count or remaining supply is reconciled at closeout when applicable

Yes No N/A

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Run: Field Trip Medication Administration Record and Skills Checklist

Trip and Inspection Details

Medication Verification and Transport

Delegated Staff Competency Checklist

Medication Administration Record

Closeout, Signatures, and Corrective Actions

Get your results