Licensing & Certification Program General Acute Care Hospital Relicensing Survey MEDICATION PASS WORKSHEET Provider Number Surveyor Name Date/Time Location/Staff Instructions: 1. Observe medication administration by facility staff. 2. Record observation of each medication administered including medications that are held. 3. Reconcile record with physician orders. Identifier Pour Pass Notes Drug Name, Strength, Discrepancies Between Observation Patient’s Name/Room # Route/Techniques of Administration Form and Quantity and Physician Orders, P&P/SOP July 2016 Page 1 of 2
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Licensing & Certification Program General Acute Care Hospital Relicensing Survey
MEDICATION PASS WORKSHEET Provider Number Surveyor Name Date/Time Location/Staff
Instructions: 1. Observe medication administration by facility staff. 2. Record observation of each medication administered including medications that are held. 3. Reconcile record with physician orders.
Identifier Pour Pass Notes Drug Name , Strength, Discrepancies Between Observation
Patient’s Name/Room # Route/Techniques of Administration Form and Quantity and Physician Orders, P&P/SOP
July 2016 Page 1 of 2
MEDICATION PASS WORKSHEET
Identifier Pour Pass Notes Drug Name, Strength, Discrepancies Between Observation
Patient’s Name/Room # Route/Techniques of Administration Form and Quantity and Physician Orders, P&P/SOP
July 2016 Page 2 of 2
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