Medication Self-Administration Assessment

Instructions

1) For all responses to items, place the letter of the choices immediately below in the “HOW” box to indicate how the answer to the question was obtained. 

W) In writing/reading  O) Orally  Sg) By Signaling U) Unable to answer Pa) By a physical action  S) By signing  

2) For all responses to items, place the letter of the choices immediately below in the “MANNER” box to indicate how the client demonstrated their capability. 

C) Chooses correct performance of activity P) Performs activity 

D) Directs performance of activity by another 

If a “NO” answer occurs for program participation or any assessment item or the client refuses to participate in a self-medication program, independent capability and functioning cannot be confirmed. The client and interdisciplinary team should, as appropriate, develop and implement a self-medication training program or a training program in preliminary skills attainment.  

If answer is YES: Proceed to Assessment 

If answer is NO or client is unable to answer:

1) STOP and complete assessment’s report section. 

2) Re-assess in one year, or as indicated. 

When program participation preference is “NO;” qualified persons must administer medications. 

When all items below are accomplished (answered “YES”), the individual is independent in self-administration of medications. Tasks must be performed at the individual’s medication storage site under visual supervision of a qualified person. Physical adaptations, supports, and/or accommodations should not prevent “YES” ratings on item performance when cognitive capacity is sufficient to support understanding. 

Assessment

Person identifies rules for safe self-administration of medication: 

a. Indicates will not share medication with others. 

b. Indicates will not take someone else’s medication. 

Person performs the necessary sanitary procedures before administration of medications: 

a. Wash or clean hands. 

b. Obtain clean utensils or containers. 

Person identifies and/or is able to recognize need to follow any special instructions that may arise connected with particular medications (i.e. Take on empty stomach, take with meals, avoid dairy products, etc.)

Person obtains the correct items for taking medications (i.e. water, applesauce, thicken, etc.)

Person identifies correct time of day to take (administer) each of their particular medications

Person removes the correct medication from the medication supply for that particular administration time.

Person removes the correct amount of the correct medication from the medication supply for that particular administration time.

Person takes the medication in the prescribed way.

Person returns medication container (supply) to the storage unit.

Person performs the necessary sanitary procedures after administration of medications: 

a. Disposing or cleaning used utensils or containers. 

b. Refrigerating necessary items (i.e. applesauce). 

Person identifies how to keep track of medications and how to obtain medication refills.

Independence

I, being a Qualified Medication Administration Personnel, do hereby certify that I have reviewed the procedure and documentation used in the self-medication assessment of this individual. I further declare that I have observed the individual perform self-medication tasks in a natural setting and I have indicated my professional opinion regarding this person’s capabilities in self-medication and self-medication training as indicated above.