Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Patient Identification

  • Are identification labels attached to all pages in the patient record? <br>1) Patient name<br>2) Date of birth<br>3) UR number<br>4) Allergy status<br>

  • Is there evidence that patient identification was confirmed before the medication was prescribed?

  • Was the patients body weight documented?

  • Are any previous 'adverse drug reactions' (ADR) documented in the record?

  • If an ADR was documented, are there alert stickers in the appropriate places?

  • If there was any previous ADR, was a similar class of medication prescribed and documented?

  • Has the status of allergy been clearly marked on the medication chart/history?

Medication History

  • Was the medical history current when the medication was prescribed?

  • Is there evidence to confirm that the medical history was checked before prescribing?

  • Is the drug name and frequency documented for variable doses?

Warfarin

  • Is there any evidence Warfarin education was given to the patient and if so, was it recorded?

Prescribing Medication

  • Are the medication orders clear with dose to be given?

  • Are the medication orders clear and legible?

  • Are the medication orders clear with route to be given?

  • Are the medication orders clear with time given?

  • Has the correct patient been given this medication?

  • Has the correct medication been given to the patient?

  • Was a repeat script documented or recorded, including when completed via phone or mail?

  • Are the required signatures present on all medication charts or notes?

  • Has the patient received discharge medication education - i.e. is there clear evidence that education has been given?

Venous Thromboembolism (VTE) Prophylaxis

  • Was there VTE prophylaxis prescribed?

  • Was there a VTE risk assessments documented on any medication chart?

PINCH -High Risk Medicines

  • PINCH class drugs prescribed?

  • Discharge education given regarding PINCH drugs?

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