Medication Audit 1

This inspection checklist can help assess the compliance with guidelines and best practices when ordering and administering medication to residents / patients, keeping MAR records, storing medication and managing controlled drugs.

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Medication Audit 1



Recording Of Medication

1. Proper completion of MAR chart (photograph of resident, name, date of birth, allergy status).


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2. Medication protocol put in place when PRN medication is used.


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3. MAR charts have no missing initials and signatures.


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4. "Refused" and "as required" medication recorded correctly on MAR chart.


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5. Any exceptions of medicine administration recorded appropriately on MAR chart.


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6. Medication protocol in place for PRN medication (staff can recognise residents require the medication if they are unable to verbalise).


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7. Care plans available and up-to-date for PRN medication.


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8. GP is notified when resident refuses their medication 3 or more times.


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9. In the case of variable dose prescriptions, there is a clear record of quantity administered.


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10. TMAR charts are fully completed (Cream/Ointment administration chart).


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11. Record of any ointment/cream administration by staff is present.


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12. Any prescribed creams/ointment when administered by staff is recorded and signed on the TMAR chart.


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13. Any home remedies that are put in practice are appropriately recorded.


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14. Evidence available of appropriate use of the pain assessment tool and administration of analgesia is informed.


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15. MAR charts checked at each shift handover to ensure their completion.


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16. Record and signature available for any prescribed thickening agents that are administered.


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Ordering & Receiving Medication

1. Record available of all medication ordered.


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2. All medicine from other sources like hospital received and properly recorded.


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3. MAR chart fully completed (date of receipt, amount received and running stock balance).


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4. MAR chart signed by 2 team members to confirm receipt of all medicine.


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5. Pharmacy medicine checked thoroughly (copy of prescriptions available and recorded in MAR).


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6. Copy of FP10 available for each medicine of each resident.


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7. Master prescription list available and signed by GP.


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8. Any verbal instructions of prescriber checked and recorded by 2 team members.


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9. Any verbal instructions only to be received for any dosage changes (not new prescriptions).


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10. Any verbal instructions confirmed in writing by prescriber within 24 hours of instructions being given.


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11. There is no overstocking of medicine present.


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Controlled Drugs

1. All controlled drugs stored securely in a locked cupboards (complies with Misuse of Drugs Regulations 1973).


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2. Controlled drugs register available in use.


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3. Register of controlled drugs are signed by 2 team members for each activity (administration, receipt, disposal).


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4. Controlled drug records are up-to-date (receipts, administration and disposal of drugs).


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5. Balances of quantities are regularly checked (at least weekly by 2 skilled team members).


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6. Controlled drugs are disposed of appropriately.


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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