Run Medication Pass Observation Audit — Free

Audit Setup and Scope

Observer identified the nurse, unit, date, and med-pass start time

Observation scope confirmed as a full medication pass critical (required)

Yes No N/A

Resident census / number of medication administrations observed

Note (optional)

Medication pass policy or facility procedure referenced

Right Resident and Order Verification

Two resident identifiers verified before each medication administration critical (required)

Yes No N/A

Medication matches the current MAR/TAR and active order critical (required)

Yes No N/A

Allergies reviewed before administration when applicable critical (required)

Yes No N/A

Medication, dose, route, and time verified against the order critical (required)

Yes No N/A

Administration Technique and Safety

Hand hygiene performed at appropriate points during the med pass critical (required)

Yes No N/A

PPE used when indicated by resident condition or medication handling requirements

Yes No N/A

Medication prepared and administered without interruption or mix-up critical (required)

Yes No N/A

Controlled substances handled according to policy when applicable critical (required)

Yes No N/A

Resident observed for immediate adverse reaction or refusal after administration

Yes No N/A

Documentation and Timeliness

Medications documented on the MAR immediately after administration or per policy critical (required)

Yes No N/A

Late, held, refused, or omitted doses documented with required reason critical (required)

Yes No N/A

PRN medication documentation includes indication and follow-up effectiveness when applicable

Yes No N/A

Documentation legible, complete, and consistent with observed administration critical (required)

Yes No N/A

Medication Error and Variance Tracking

Number of medication errors observed critical (required)

Note (optional)

Number of near misses or intercepted errors observed

Note (optional)

Observed error rate calculated as errors divided by total administrations

Note (optional)

Variance escalated to charge nurse, supervisor, or per facility policy critical (required)

Yes No N/A

Closeout and Corrective Actions

Overall audit result critical (required)

Note (optional)

Corrective action plan documented for any deficiency or non-conformance

Yes No N/A

Follow-up audit or re-education scheduled if needed

Note (optional)

Inspector signature critical (required)

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Run: Medication Pass Observation Audit

Audit Setup and Scope

Right Resident and Order Verification

Administration Technique and Safety

Documentation and Timeliness

Medication Error and Variance Tracking

Closeout and Corrective Actions

Get your results