Official Federal Forms > Centers For Medicare And Medicaid Services
Medication Pass Worksheet CMS-677 - Official Federal Forms
| Medication Pass Worksheet Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICATION PASS WORKSHEET Provider Number Surveyor Name Date Error Rate Instructions: 1. Observe Pass for 20-25 opportunities for error. If one or more errors is found observe another 20-25 opportunities for error. 2. Record your observation of each opportunity for error. 3. Compare your record with physician orders. 4. Calculate and note error rate Deficiency Formulas: Significant Error + Non-Significant Error X 100 = 5% = Deficiency 1. One or more Significant Errors = Deficiency 2. Doses given + Doses ordered but not given Identifier Pour Pass Record Drug Prescription Name, Drug Order Written As Residents Full Name Observation of Administration Dose and Form (when different from observation)FORM CMS-677 (07/95) <<<<<<<<<********>>>>>>>>>>>>> 2 MEDICATION PASS WORKSHEET Identifier Pour Pass Record Drug Prescription Name, Drug Order Written As Residents Full Name Observation of Administration Dose and Form (when different from observation)FORM CMS-677 (07/95)
|
|||||||
