Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Assemble equipment.
2. ✦ Perform hand hygiene.
3. ✶ Select the correct medication as
instructed in the “three befores.”
If you are not familiar with the
medication, look it up in a
reference book, read the package
insert, or consult the physician.
4. ✶ Always double-check the label
to make sure the strength is
correct, because medications
are manufactured with dierent
strengths.
5. ✶ Correctly calculate the dosage
in writing. Double-check your
calculations.
6. ✦ Place a medicine cup/container on
a flat surface.
7. ✶ Shake the tablet ordered into
the bottle cap and then into a
medication container.
8. ✶ Check the dosage again against
the medication order.
9. ✦ Replace the cap on the
medication bottle, and return the
bottle to the storage shelf after
reading the label again.
10. ✶ Introduce yourself and warmly
greet and identify the patient,
both by stating his or her name
and examining any printed
identification such as a wrist
name band or medical record.
Ask the patient to state his or her
date of birth. Ask if the patient has
any allergies.
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