AHS - Medication Titration Audit Tool 2020

• Conducted on

  Date

• Prepared by

• Campus

  Select

• Clinical Location

Medication #1

• Patient Identifier

• Prescriber

• Date/Time of order

  Date

• Name of Medication

• Was there an order for the incremental units the rate can be increased or decreased (e.g. 5mcg)?

  Yes

  No

• What was the incremental units the rate can be increased or decreased?

• Was there an order for the frequency of incremental dose titration (e.g. every 5 minutes)?

  Yes

  No

• What is the frequency of incremental dose titration change?

• Was there a clinical goal specified (e.g. RASS Score, SBP, HR, MAP)?

  Yes

  No

• What was the clinical goal ordered (e.g. RASS Score of -2, SBP > 90)?

• Was there a maximum rate/dose ordered or when to call the ordering LIP (e.g. do not exceed 20mcg/kg/min or call for HR greater than 120)?

  Yes

  No

• What was the maximum rate/dose ordered or call parameter?

• What was the ordered starting rate/dose of the infusion?

• Start date/time of infusion

  Date

• Time of first adjustment

  Date

• Was the first adjustment compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#2)

  Date

• Was adjustment #2 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#3)

  Date

• Was adjustment #3 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#4)

  Date

• Was adjustment #4 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#5)

  Date

• Was adjustment #5 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#6)

  Date

• Was adjustment #6 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#7)

  Date

• Was adjustment #7 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#8)

  Date

• Was adjustment #8 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Comments

Medication #2

• Patient Identifier

• Prescriber

• Date/Time of order

  Date

• Name of Medication

• Was there an order for the incremental units the rate can be increased or decreased (e.g. 5mcg)?

  Yes

  No

• What was the incremental units the rate can be increased or decreased?

• Was there an order for the frequency of incremental dose titration (e.g. every 5 minutes)?

  Yes

  No

• What is the frequency of incremental dose titration change?

• Was there a clinical goal specified (e.g. RASS Score, SBP, HR, MAP)?

  Yes

  No

• What was the clinical goal ordered (e.g. RASS Score of -2, SBP > 90)?

• Was there a maximum rate/dose ordered or when to call the ordering LIP (e.g. do not exceed 20mcg/kg/min or call for HR greater than 120)?

  Yes

  No

• What was the maximum rate/dose ordered or call parameter?

• What was the ordered starting rate/dose of the infusion?

• Start date/time of infusion

  Date

• Time of first adjustment

  Date

• Was the first adjustment compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#2)

  Date

• Was adjustment #2 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#3)

  Date

• Was adjustment #3 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#4)

  Date

• Was adjustment #4 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#5)

  Date

• Was adjustment #5 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#6)

  Date

• Was adjustment #6 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#7)

  Date

• Was adjustment #7 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#8)

  Date

• Was adjustment #8 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Comments

Medication #3

• Patient Identifier

• Prescriber

• Date/Time of order

  Date

• Name of Medication

• Was there an order for the incremental units the rate can be increased or decreased (e.g. 5mcg)?

  Yes

  No

• What was the incremental units the rate can be increased or decreased?

• Was there an order for the frequency of incremental dose titration (e.g. every 5 minutes)?

  Yes

  No

• What is the frequency of incremental dose titration change?

• Was there a clinical goal specified (e.g. RASS Score, SBP, HR, MAP)?

  Yes

  No

• What was the clinical goal ordered (e.g. RASS Score of -2, SBP > 90)?

• Was there a maximum rate/dose ordered or when to call the ordering LIP (e.g. do not exceed 20mcg/kg/min or call for HR greater than 120)?

  Yes

  No

• What was the maximum rate/dose ordered or call parameter?

• What was the ordered starting rate/dose of the infusion?

• Start date/time of infusion

  Date

• Time of first adjustment

  Date

• Was the first adjustment compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#2)

  Date

• Was adjustment #2 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#3)

  Date

• Was adjustment #3 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#4)

  Date

• Was adjustment #4 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#5)

  Date

• Was adjustment #5 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#6)

  Date

• Was adjustment #6 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#7)

  Date

• Was adjustment #7 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#8)

  Date

• Was adjustment #8 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Comments

Medication #4

• Patient Identifier

• Prescriber

• Date/Time of order

  Date

• Name of Medication

• Was there an order for the incremental units the rate can be increased or decreased (e.g. 5mcg)?

  Yes

  No

• What was the incremental units the rate can be increased or decreased?

• Was there an order for the frequency of incremental dose titration (e.g. every 5 minutes)?

  Yes

  No

• What is the frequency of incremental dose titration change?

• Was there a clinical goal specified (e.g. RASS Score, SBP, HR, MAP)?

  Yes

  No

• What was the clinical goal ordered (e.g. RASS Score of -2, SBP > 90)?

• Was there a maximum rate/dose ordered or when to call the ordering LIP (e.g. do not exceed 20mcg/kg/min or call for HR greater than 120)?

  Yes

  No

• What was the maximum rate/dose ordered or call parameter?

• What was the ordered starting rate/dose of the infusion?

• Start date/time of infusion

  Date

• Time of first adjustment

  Date

• Was the first adjustment compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#2)

  Date

• Was adjustment #2 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#3)

  Date

• Was adjustment #3 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#4)

  Date

• Was adjustment #4 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#5)

  Date

• Was adjustment #5 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#6)

  Date

• Was adjustment #6 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#7)

  Date

• Was adjustment #7 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#8)

  Date

• Was adjustment #8 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Comments

Medication #5

• Patient Identifier

• Prescriber

• Date/Time of order

  Date

• Name of Medication

• Was there an order for the incremental units the rate can be increased or decreased (e.g. 5mcg)?

  Yes

  No

• What was the incremental units the rate can be increased or decreased?

• Was there an order for the frequency of incremental dose titration (e.g. every 5 minutes)?

  Yes

  No

• What is the frequency of incremental dose titration change?

• Was there a clinical goal specified (e.g. RASS Score, SBP, HR, MAP)?

  Yes

  No

• What was the clinical goal ordered (e.g. RASS Score of -2, SBP > 90)?

• Was there a maximum rate/dose ordered or when to call the ordering LIP (e.g. do not exceed 20mcg/kg/min or call for HR greater than 120)?

  Yes

  No

• What was the maximum rate/dose ordered or call parameter?

• What was the ordered starting rate/dose of the infusion?

• Start date/time of infusion

  Date

• Time of first adjustment

  Date

• Was the first adjustment compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#2)

  Date

• Was adjustment #2 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#3)

  Date

• Was adjustment #3 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#4)

  Date

• Was adjustment #4 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#5)

  Date

• Was adjustment #5 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#6)

  Date

• Was adjustment #6 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#7)

  Date

• Was adjustment #7 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Time of next adjustment (#8)

  Date

• Was adjustment #8 compliant with the ordered frequency/incremental dose?

  Yes

  No

  N/A

• Why?

• Was the reason documented?

  Yes

  No

• Comments