AAM: Division of Developmental Disabilities Services July 2008  
MEDICATION PASS CHECKLIST 
Person Being Observed:__________________ Location:___________ Date: ___________ AAM: Division of Developmental Disabilities Services July 2008  
Steps  Yes  No  Comments  
1. Positively identify the individual you will be giving the medication to  
 
 
2. Wash hands  
 
 
3. Gather all necessary utensils (i.e. glasses, water, spoons, etc.)  
 
 
4. Unlock the storage area  
 
 
5. Read Medication Record       9 Identify right medication   Take medication from storage area  
 
 
6. Compare the pharmacy label to the      9 Medication Record. Make sure all information matches  
 
 
7. Prepare an accurate dose make sure it is 9 the right dose and the right strength Sign count sheet for countable medications Compare the pharmacy label to the medication record again  
 
 
8. Assist with the administration of medication to the right individual by the right method. Make sure the individual is in the right position to receive the medication. (If oral) Make sure the individual swallows the medication. REMEMBER: LOCK THE STORAGE AREA WHEN YOU LEAVE  IT TO GIVE THE MEDICATION.  
 
 
9. Document medication you gave, 9 compare pharmacy label to the medication record  
 
 
10.Return the medication to the correct storage area.   Lock the storage area  
 
 
11.Wash hands  
 
 
12.Observe the individual for any unusual or adverse effects  
 
 
Observer Name:       Job Title: Signature of Observer:       Medication Type:  


Remember the 7 RIGHTS 



FOUR CHECKS 9

9 READ THE MEDICATION ADMINISTRATION RECORD AND IDENTIFY THE RIGHT MEDICATION 
9 COMPARE THE PHARMACY LABEL TO THE MEDICATION RECORD 
9 PREPARE MEDICATION; MAKE SURE IT’S THE RIGHT DOSE AND THE RIGHT STRENGTH 
9 DOCUMENT MEDICATION; COMPARE THE PHARMACY LABEL TO THE MEDICATION SHEET