SELF MANAGEMENT OF MEDICATION EVALUATION
NAME: ___________________________________________ Date: ____/____/____
Purpose: To observe and assess the reliability and predictability of a person to self-manage
medications safely.
Procedure: Administer this evaluation ONLY to individuals who have already been assessed to
be INDEPENDENT in self-medication administration.
Observations Yes No Comments
1. Can the person tell you the name of the
medication?
2. Can the person tell you what the medication is
for?
3. Can the person tell the most common side
effects of the medication?
4. Does the person know what they need to call
the nurse or doctor for?
5. Does the person know how to call the nurse
and/or doctor?
6. Does the person know not to give his/her
medication to others? (Ask the person what s/he
would do if another person asked him/her for
his/her medications?)
7. Does the person know not to replace his/her
medication with another person’s medication?
(Ask consumer what s/he would do if s/he ran out
of medication)
8. Does the person know not to change his/her
medication dose(s) without consulting his/her
health care provider?
9. Does the person know when it is time to refill
the prescription?
10. Does the person know how to refill
prescriptions?
11. Does the person know that if the pills look
different they should ask the pharmacist before
taking it?
14. Can the person lock medication in an
approved storage box (if this is required)?
15 Is the box and key kept in a safe and
accessible place?
16. Can the person indicate on an MAR that
medication was taken? (if this is required)
IF USING A PILL ORGANIZER: Can the person
independently correctly fill the pill organizer?
Complete assessment on other side
Self-Medication MANAGEMENT Evaluation Determination
Based on the observations and assessment, I have determined that the person:
Is capable of self-managing medication INDEPENDENTLY.
(occasional monitoring by RN, LPN or AMAP)
Is not capable of self-managing medication. The person needs assistance,
supervision and/or additional instruction in the following areas:
___ Names of medications ___ How to call the nurse/doctor
___ Purpose of medication ___ What to do if another person asks
for his/her medication
__ Importance of not changing dose
without permission from their ___ When and how to order medication
health care provider refill
___ Common side effects ___ How to store medication
___ What to call nurse/doctor for ___ IF USING A PILL ORGANIZER:
correctly filling the pill organizer
RN: _____________________________________________________ Date: ____/____/____
Additional Notes: ______________________________________________________________
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