RDHM Medication Audit

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was the patients body weight documented?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Medication History

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Warfarin

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

  Yes

  No

  N/A

Prescribing Medication

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

  Yes

  No

  N/A

• Are the medication orders clear and legible?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are the medication orders clear with time given?

  Yes

  No

  N/A

• Has the correct patient been given this medication?

  Yes

  No

  N/A

• Has the correct medication been given to the patient?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Venous Thromboembolism (VTE) Prophylaxis

• Was there VTE prophylaxis prescribed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

PINCH -High Risk Medicines

• PINCH class drugs prescribed?

  Yes

  No

  N/A

• Discharge education given regarding PINCH drugs?

  Yes

  No

  N/A