Run Self-Administration of Medication Assessment — Free

Assessment Details

Resident identified and assessment date documented critical (required)

Assessment completed by interdisciplinary team member(s) critical (required)

Note (optional)

Reason for assessment documented

Current medication list reviewed against resident's report critical (required)

Yes No N/A

Cognitive Ability and Understanding

Resident is oriented to person, place, and situation sufficiently to manage medications critical (required)

Yes No N/A

Resident can state medication names or recognize medications by appearance

Yes No N/A

Resident can explain purpose and schedule for each medication critical (required)

Yes No N/A

Resident demonstrates understanding of missed-dose or refusal process

Yes No N/A

Resident demonstrates safe judgment regarding sharing, hoarding, or duplicating medications critical (required)

Yes No N/A

Physical Ability and Medication Handling

Resident can read medication labels or has an approved accommodation to do so critical (required)

Yes No N/A

Resident can open medication containers or blister packs safely critical (required)

Yes No N/A

Resident can manipulate pills, inhalers, drops, or other prescribed dosage forms as applicable

Yes No N/A

Resident can follow the prescribed route of administration without assistance critical (required)

Yes No N/A

Medication Storage and Room Safety

Medication storage area in resident room is secure and inaccessible to unauthorized persons critical (required)

Yes No N/A

Medications are stored separately from food, chemicals, and other prohibited items critical (required)

Yes No N/A

Medications requiring refrigeration are stored at proper temperature

Yes No N/A

Controlled substances, if applicable, are managed according to facility policy and state requirements critical (required)

Yes No N/A

Self-Administration Outcome and Plan

Resident is approved to self-administer medications independently critical (required)

Yes No N/A

If not fully independent, level of assistance is clearly documented

Note (optional)

Resident and responsible party informed of assessment outcome

Yes No N/A

Follow-up plan, restrictions, or retraining documented

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Run: Self-Administration of Medication Assessment

Assessment Details

Cognitive Ability and Understanding

Physical Ability and Medication Handling

Medication Storage and Room Safety

Self-Administration Outcome and Plan

Get your results