Medication Pass Observation
To be completed at the time of the medication pass observation. Both the Employee being observed and the Trainer/ Person observing will need to sign the form after the successful completion of the medication pass.
Date:
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Month
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Employee Name: (Please capitalize the first and last name)
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First Name
Last Name
Trainer/ Observer Name:
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Trainer/ Observer Title:
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Location: (Community Living Site #)
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Please Select
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Duration:
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Medication Pass Time:
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Mark the appropriate checkbox for each step and provide comments as needed.
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Pass
Needs Improvement
Comments
Performs hand hygiene before preparing medications
Selects the correct Medication Administration Record (MAR)
Verifies the right person using two identifiers
Selects the right medication from storage
Checks medication label against the MAR
Confirms the right dose
Confirms the right route
Confirms the right time
Prepares medication without contamination
Explains procedure to the individual
Positions individual appropriately for administration
Administers medication correctly
Ensures medication is swallowed or taken as prescribed
Performs hand hygiene after administration
Documents administration immediately on the MAR
Documents administration immediately on the medication packaging (initials & date). As applicable.
Reports any issues, errors, or refusals per policy
Maintains individual’s privacy and dignity throughout
Completion Status:
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Medication pass has been successfully completed
Employee Signature: I acknowledge that I am confident and competent in administering medications in accordance with Noble’s procedures. I affirm my commitment to consistently follow Noble’s medication administration protocols, including adherence to the Six Rights of Medication Administration, at all times during my employment with Noble.
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Trainer/ Observer Signature:
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Date
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Month
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Day
Year
Date
If you would like a copy of the training please enter your email address:
example@example.com
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CL Medication Administration Check Off Created: 2/2026
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