Form Cms-20056 - Medicare Adminstration Observation Page 2

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Medication Administration Observation
CENTERS FOR MEDICARE & MEDICAID SERVICES
Prescriber’s Order If
Adminis­
Drug / Dosage / Route
Administration Error
Date/Time
Resident Name
Room/Bed
tration
Staff Name
(oral, enteral, intravenous, intramuscular, subcutaneous, topical, optical,
(Describe Error as
etc.)
Error
Necessary)
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2
FORM CMS–20056 (5/2013)

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