Collaborative Medicines Related Discharge Audit Form

• Collaborative Medicines Related Discharge Audit

• Ward/Clinical Area

• Conducted on

  Date

• Prepared by

• List of codes

  

Discharge Prescription 1

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 2

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 3

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 4

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 5

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 6

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Discharge Prescription 7

• Where was the prescription screened:

  Ward

  Dispensary

  Other

• Ward/Clinical area where prescription was screened:

• Electronic Discharge:

  Yes E

  Yes H

  No

• Care area:

  Medical

  Surgical

  Paediatrics

  MH

  CHS

• Elective patient:

  Yes

  No

  Unknown

• Number of prescribed items on discharge prescription:

• Allergy status documented:

  Yes

  No

Contribution 1:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 2:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 3:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 4:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 5:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

Contribution 6:

• Contribution descriptor:

  Select A - Allergy Status B - Omitted Drug C - Innapropriate Addition D - Wrong Drug E - Wrong or missing dose F - Wrong or missing formulation or route G - Wrong frequency, timing or duration H - Drug Interaction I - Legality J - Information on changed medicines K - GP actions required L - MCA required M - Other

  • A - Allergy Status
  • B - Omitted Drug
  • C - Innapropriate Addition
  • D - Wrong Drug
  • E - Wrong or missing dose
  • F - Wrong or missing formulation or route
  • G - Wrong frequency, timing or duration
  • H - Drug Interaction
  • I - Legality
  • J - Information on changed medicines
  • K - GP actions required
  • L - MCA required
  • M - Other

• Clinical impact of contribution:

  Level 1 - None/Insignificant

  Level 2 - Low/Minor

  Level 3 - Moderate

  Level 4 - Severe/Major

• Medicine involved:

• Changes since admission recorded with reasons:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• GP actions documented by prescriber:

  Yes - Fully

  Yes - Partly

  No

  Not Required

• Consultation Details Clear:

  Yes

  No

• PMR

  No

  Yes - A

  Yes - B

  Yes - C

• Time for clinical screen (minutes):

• Time between identification and resolution of problems (minutes):

Details of Person completing audit:

• Add signature

  Sign

• Select date

  Date