Form Cms-677 - Medication Pass Worksheet
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1
2DEPARTMENT OF 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
Observation of Administration
Resident’s Full Name
Dose and Form
(when different from observation)
FORM CMS-677 (07/95)
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Parent category: Medical