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?

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.