Medication Pass Observation
To be completed at the time of the medication pass observation. Both the Employee being observed and the Nurse observing will need to sign the form.
Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee Name: (Please capitalize the first and last name)
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First Name
Last Name
Trainer:
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Please Select
Joanne Hester, Nurse
Marlin King, Nurse
Emily Scifres, Nurse
Chad Linn, VP of Compliance & Operations, Nurse
Kiara Bishop, Nurse
Kiersten Labanauskas, Nurse
Other
Trainer Name:
*
Trainer Email Address:
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example@example.com
Location of Training:
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Please Select
Noble East
Noble West
Noblesville
Noble Art
Other
Location of Training:
*
Duration:
*
Mark the appropriate checkbox for each step and provide comments as needed.
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Rows
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:
*
Simulated medication pass
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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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Observer/ Nurse Signature: (Please capitalize the first and last name)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Medication Administration Check Off Created: 4/7/25
Should be Empty: