SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.

2772-2774 Roxas Boulevard, Pasay City 1300 Philippines

ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE

DRUG ADMINISTRATION PERFORMANCE CHECKLIST

INTRAMUSCULAR INJECTION

Name: ___________________Year and Section: ______________Date:_____________

CRITERIA 4 3 2 1 0 Remarks
ASSESSMENT
1. Check accuracy and completeness of medication card
with medication orders on the Physician’s order sheet,
against the standing order and medication sheet.
2. Assess patient’s medical and medication history.
3. Assess patient’s history of allergies.
4. Assess for contraindication to IM injections/medications
and history of severe adverse reaction to IM injections
/medications.
5. Assess knowledge of the patient of the purpose of IM
injections.
PLANNING
1. Identify expected outcome.
IMPLEMENTATION
1. Perform hand hygiene and prepare supplies.
2. Prepare the drugs by:
2.1. Get correct drug from the box of the patient.
2.2. Check drug dosage and expiration date.
2.3. Compute drug dose to be given, double-check the
computation.
3. Preparation of vial containing solution:
3.1. Removed cap covering of the vial, wipe surface of
rubber seal with alcohol, allow to dry.
3.2. Pick up syringe, remove cap, draw amount of air into
the syringe equal to the amount of medication to be
aspirated.
3.3. Insert needle to center of the rubber seal and inject
air into air space of the vial, hold plunger firmly.
3.4. Invert vial keep tip of needle below fluid level,
aspirate desired amount of solution.
3.5. Remove needle from the vial, expel air bubbles.
3.6. Change needle to appropriate syringe.
4. Take medication to patient and apply the (10) Rights of
drug administration.
5. Inform patient of the purpose.
FOR INTRAMUSCULAR:
1. Select site for IM injection, appropriate for client’s size
and age. (Deltoid or gluteal) Assist client into position for
comfort and easy visibility of injection site
2. Clean site with antiseptic swab, grasp the muscle using
non-dominant hand.
3. Remove needle cap, inject needle at 90-degree angle
quickly.
4. Hold the barrel of the syringe with non-dominant hand,
aspirate to check for blood return.
5. If no blood returns, push plunger slowly until all
solutions are injected.
6. Withdraw needle quickly, apply pressure using dry
cotton balls. Reposition client comfortably.
7. Do after care of materials use. Wash hands.
 SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 Roxas Boulevard, Pasay City 1300 Philippines
ISO 9001 (Quality); ISO 14001 (Environment); OHSAS 18001 (Health & Safety) CERTIFIED - HOSPITAL
Asia’s 1st Hospital Certified in OHSAS
First Philippine Hospital Certified in EMS and with Triple Certification
PAASCU Accredited – COLLEGE

8. Fill up medication sheet and document reaction of

client.
EVALUATION
1. Report and record outcome / undesirable effects (If
there is any).
1.1. Time injection was given/not given.
1.2. Response of client, untoward reaction of client.

Total Score: ______________/80

NARRATIVE NOTE GRADING RUBRICS:

POINTS CRITERIA
4 Student was able to follow the procedure guidelines given with great accuracy,
completeness, confidence, consistency, poise within the allotted time
3 Student was able to compose oneself while doing every step of the procedure guidelines
with accuracy, confidence and consistency within the allotted time
2 Student had done every step of the procedure guidelines but showing a little unprepared,
needs some improvement within the given time.
1 Student is not prepared, showed more nervousness, there is inaccuracy with procedures not
effective due to errors.
0 Not Performed

Comments/ Suggestions:

______________________ __________________________
Signature of Student Signature of Clinical Instructor