• Document No.

  • Conducted on

  • Prepared by

Patient One

  • NHS Number

  • Name of drug and dose prescribed?

  • Who currently administers medication?

  • Could this patient be delegated to an HCA or AP?

  • Were all doses in the last 4 weeks given on time ? ( +/- 30 minutes of prescribed time )

  • If no, how many doses were missed?

  • How many doses were delayed by more than 30 minutes?

  • Was insulin administered in the last month?

  • What is the reason that the team has taken on administration of insulin for this patient?

  • How frequently is insulin prescribed for administration?

  • Does anyone else administer the insulin?

  • Has a clear communication plan been established?

  • Any further comments you wish to add?

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