Medication Audit - Individual v2.0

• Document No.

• Site:

• Type of Audit:

  Full Quality Audit

  Specific Qulaity Audit

  Urgent Quality Audit

  Follow-Up Audit

• Reason for Audit

• Reason for Audit

• Conducted on

  Date

• Conducted By:

  Sign

• Any relevant Information

• Resident Name:

• Date of Birth:

  Date

• Room Number:

• Admission Date:

  Date

IDENTIFICATION

• Is there a photo ID card/divider between Residents MAR?

  YES

  NO

• Is there a photo ID card/divider between Residents Medication Stored in Racks / Dispensers?

  YES

  NO

• Is the Allergy Status recorded on the photo ID card / MAR or Other easily identified area when Administering Medication?

  YES

  NO

• Is the persons name clearly identified on the Pharmacy Issued MAR and Pharmacy Medication Labels?

  YES

  NO

• Is the persons name clearly identified on all Handwritten MAR?

  YES

  NO

  Not Applicable

MAR SHEETS - GENERAL

• Record All Medications Resident is currently Prescribed for:

• Are dates and quantities of Medications received, recorded on the Pharmacy MAR?

  YES

  NO

• Are they 'Initialed'

  YES

  NO

• Are 'Carried Forward' quantities recorded on the MAR?

  YES

  NO

  Not Applicable

• Are they 'Initialed'

  YES

  NO

• Is there an appropriate code or signature for all doses administered?

  YES

  NO

• Are dosage times written in the appropriate places and easily identified?

  YES

  NO

• If 'Colour Coding' is used, is it Consistent?

  YES

  NO

  Not Applicable

• Are variable doses required?

  Yes

  No

• Are they recorded correctly?

  YES

  NO

• Are there any 'HANDWRITTEN' Sheets?

  NO

  YES

• Are all Medications written exactly the same as the label?

  YES

  NO

• Is the Handwriting 'Legible'?

  YES

  NO

• Are there two Signatures for the entry?

  YES

  NO

• Does the Label and MAR include any special instructions? ( With food, take with a full glass of water)

  YES

  NO

  Not Applicable

• Do the medicines administered tally with the remaining medicines?

  YES

  NO

• Record which Medications do not 'Tally':

• Is the administration of all topical preparations recorded?

  YES

  NO

  Not Applicable

CONTROLLED DRUGS

• Is the Resident taking any controlled drugs at this time?

  YES

  Not Appicable

• Are the Residents CD's stored in a metal 'Locked' cupboard/cabinet?

  YES

  NO

  Not Applicable

• Is the CD Register a 'Hard Bound Book' with numbered pages?

  YES

  NO

• Are balances recorded correctly and countersigned with a second signature?

  YES

  NO

• Do CD balances match current stock?

  YES

  NO

• Are alterations or errors correctly entered?

  YES

  NO

  Not Applicable

• Are CD's disposed of correctly when required? Check Log Sheets

  YES

  NO

  Not Applicable

• Are there 2 signatures for all entries in the CD book?

  YES

  NO

• Are Regular Stock Checks recorded? (Minimum weekly)

  YES

  NO

PRN MEDICATION - (As Required)

• Is any Medication Prescribed as 'PRN'? (As Required)

  YES

  Not Appicable

• Is there 'Proof' that the Medication is 'Offered'?

  YES

  NO

• How is this Evidenced?

• When Medication is 'Given' is the reason and quantity, Recorded Correctly?

  YES

  NO

  Not Applicable

Homely Remedies

• Are any 'Homely Remedies' given to the Resident?

  YES

  Not Appicable

• List the Products:

• Are they given in accordance with 'Documented Approval'?

  YES

  NO