Download Medication Chart Audit Tool Auditor Name

Medication Chart Audit Tool
1. Auditor Name …………………………………
2. Health facility (please tick a box)  1  2
3. Ward/ Unit Area ……………………………………
4. Audit Date …………………………………………..
5. Audit Time …………………………………………..
Medical Record Number (MRN) …………………………………………..
Age …………………………………………
Gender  Male  Female
Reason for Admission/ Diagnosis ………………………………………………………………
Total No of medications charted (In the last 24 hours) ……………………………………….
Number of administration events (In the last 24 hours) ………………………………………
Number of omissions With Documentation (In the last 24 hours)
……………………………………
If any complete separate sheet No 1 “Omissions with Documentation”
Number of omissions Without Documentation (In the last 24 hours)
……………………………….
If any complete separate sheet No 2 “Omissions Without Documentation”
Master Data Collection Tool, Version 1.0, 04 October 2013
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Instructions for completing the medication chart audit tool
Omission error: Omission errors occur when a patient fails to receive a dose of medication that
was ordered by the time the next dose is due. Omission error without documentation (no
signature or explanatory code) is what is being studied in this trial.
Auditor Name: Name of data collector.
Medical Record Number (MRN): Unique identifying patient record number. The MRN helps
identify patients to avoid auditing the same patient more than once.
Reason for Admission/ diagnosis: Information found in the Nursing Handover summary sheet
on the respective ward or unit under the title Reason for Adm/Proc.
Total number of medications charted: The total amount of medications charted in the
medication chart in the last 24 hours from the date and time of the audit. Including all Regular
Medications and medications charted in the Once Only, Pre-Medications & Nurse Initiated
Medicines section of the chart. PRN medications are not included in the collection. All current
medication charts belonging to the patient need to be included in the audit as some patients have
multiple charts.
Number of administration events: The total number of medication administration events in the
last 24 hours from the date and time of the audit according to the frequency of administration of all
medications charted. For example if one of the medications is charted to be administered TDS
(three times per day) at 0600-1400-2200 and the audit is happening at 0800 hours the patient
should have received 3 doses of the medication at the time of the audit.
Number of omissions: Identify medications not signed and therefore not given at the specified
time according to the written orders on the medication charts. The data collectors will also collect
details of medications not administered as charted for some other reason such as nil stock, or
withholding medications according to policy (e.g. F indicating fasting).
Number of omission with documentation: Omissions when there is a reason notated in the
chart. If any, complete separate sheet No 1 called “Omissions With Documentation” and follow
instructions.
Number of omission without documentation: Omissions when there is no documentation in the
chart or not being signed (blank). If any, complete separate sheet No 2 called “Omissions Without
Documentation” and follow instructions.
Details of missed medications: Complete sheet No 1 for omissions with documentation and
Sheet No 2 for omissions without documentation. See instructions on the corresponding sheets.
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Sheet No 1
Omissions With Documentation
Event
Medication Name
Dose
Frequency (Circle)
Route (Circle)
Date & Time
Documentation (Circle)
missed
1
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
2
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
3
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
4
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
5
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
6
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
7
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
8
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
9
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
10
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
A F R V L N W S Other
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Sheet No 1
Omissions With Documentation Codes
Frequency:
Daily: Every day
Mane: Morning
Nocte: Night
BD: Twice per day
TDS: Three times per day
QID: Four times per day
Other: Any other codes
Route:
PO: Per oral or oral route
SC: Subcutaneous
IM: Intramuscular
IV: Intravenous
Neb: Nebulised or inhaled
Top: Topical
PR: Per rectum or anal route
Other: Any other codes
Documentation:
A Absent / F Fasting / R Refused / V Vomiting / L Leave / N Not Available / W Withheld / S Self Administered / Other
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Sheet No 2
Omissions Without Documentation
Event
Medication Name
Dose
Frequency (Circle)
Route (Circle)
Date & Time
missed
1
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
2
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
3
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
4
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
5
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
6
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
7
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
8
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
9
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
10
Daily Mane Nocte BD TDS QID Other
PO SC IM IV Neb Top PR Other
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Comments
Sheet No 2
Omissions Without Documentation Codes
Frequency:
Daily: Every day
Mane: Morning
Nocte: Night
BD: Twice per day
TDS: Three times per day
QID: Four times per day
Other: Any other codes
Route:
PO: Per oral or oral route
SC: Subcutaneous
IM: Intramuscular
IV: Intravenous
Neb: Nebulised or inhaled
Top: Topical
PR: Per rectum or anal route
Other: Any other codes
Figure 2. Medication Chart Audit Tool
Master Data Collection Tool, Version 1.0, 04 October 2013
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