Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Review the physician’s patient
medication orders.
2. ✶ Ensure that you are selecting the
correct medication according
to the physician’s orders, and
properly putting it back in storage
after use, by adhering to the
“three befores.” [Recite to your
instructor the “three befores” that
are required for checking and
selecting the correct medication.]
3. ✶ Ensure that have observed the
“six rights” before you administer
a medication. [Recite to your
instructor the “six rights” of
medication administration that
must be confirmed before
administering medication to a
patient.]
4. ✶ Ensure that you observe the
additional “four rights” in the
course of administering a
medication. [Recite to your
instructor the additional “four
rights” that must be considered
when administering a medication
to a patient.]
GRADING
Points Earned
Points Possible 33 33
Percent Grade (Points Earned/
Points Possible)
PASS: ❑ YES
❑ NO
❑ N/A
❑ YES
❑ NO
❑ N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
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