Audit

Patient Identification

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

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?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.