TAGUM DOCTORS COLLEGE, INC.

Mahogany St., Rabe Subd., Tagum City

Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

ADMINISTRATION OF THERAPEUTIC AGENTS

PERFORMANCE CHECKLIST
ADMINISTRATION OF MEDICINE BY MOUTH

Name: ________________________________________ Grade: ______________

Year: _________________________________________ Date: _______________

Legend: 5 - Excellent 4 - Very Good 3 - Good 2 - Fair 1 - Poor

RATING
5 4 3 2 1
1. Checks Physician’s order and finds the corresponding medication tickets
2. Arranges the tickets in order in the medication tray
3. Washes hands
4. Brings requisites to preparation area.
5. Takes one medicine ticket at a time.
6. Reads first the ticket, locates medicine in the box, reads label and notes also the
expiration date. Removes medicine from the box.
7. Compares name of drug on label with name of drug on medicine ticket.
8. Pours or prepares prescribed dosage of medicine in glass as follows:
Liquids/Suspension
A. Shakes bottle if necessary
B. Removes cap and places it upside down on the counter
C. Holds medicine glass at eye level
D. Places thumb on prescribed level and reads it at the lower meniscus
E. Pours the exact amount of medicine prescribed into the medicine glass.
F. Wipes rim of bottle with tissue paper and replaces cap.
Tablets, Pills, Capsules
A. If in a bottle, gently shakes the prescribed number into the bottle cover.
B. If in a box, shakes prescribed number into the medicine glass.
9. Rechecks label of medicine and dosage with the medicine ticket before returning
to its medicine box.
10. Places ticket with corresponding medicine on tray
11. Takes each remaining ticket in turn until all medicines and tickets are on the
tray
12. Places each medicine in a separate container.
13. Keeps medication ticket and drug together at all times.
14. Presents prepared medicines and medication booklet to CI for checking.
15. Transports medications to the client’s bedside carefully and keeps the
medication tray in sight at all times.
16. At each client’s bedside:
A. Identifies client by asking client to state his/her name or by checking the
wrist band against the medication ticket.
B. Assists client to sit or be in comfortable position
C. Hands medicine to client
D. Hands drinking water to client(if not contraindicated)
E. Stays at bedside until client takes the medicine. Makes client comfortable
F. Turns medicine ticket to show that medicine has been given
17. Returns medication ticket to the place provided for them
18. After care of equipment: Soaps, rinses, and dries equipment used and returns
to proper places.
19. A. Initialize the medication sheet to the corresponding drug, time, and date.
B.On the nurse’s notes, documents the:
B.1 drug, dose, time, route given
B.2 significant symptoms in relation to drug/s
B.3 Drug/s that have not been given and reason for omission
B.4 signature
20. Maintains body mechanics throughout the performance of the procedure
21. Manifests neatness in the performed procedure
22. Receptive to criticisms.
23. Observes courtesy
24. Calmness while performing the procedure
25. Uses correct English
26. Shows mastery of the procedure

Remarks:
 TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subd., Tagum City
Telefax: (084) 655 – 6971 E-Mail: tdci_007@yahoo.com
Website: TagumDocollege.com

Student’s Signature: ___________________________________________ Date: _______________

CI’s Signature: ________________________________________________ Date: ________________