2.1 Example of medication chart audit
This is an example only that should be adapted in accordance with the policies of the Medication Advisory Committee.
Data collected by: Date:
Resident code Res Res Res Res Res Res Res Res Res Res
Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 1. Has this resident’s name been written clearly and correctly in the medication chart? 2. Has this resident’s Date of Birth been written in the medication chart? 3. Has the status of ‘Allergy’ been clearly marked on the medication chart? 4. Is the doctor’s signature present on all medication orders? 5. Is the ‘date of order’ written on all medications orders by the doctor? 6. Are the medication orders clear and legible? 7. Are the medication orders clear with dose to be given? 8. Are the medication orders clear with route to be given? 9. Are the medication orders clear with time to be given? 10. Are there any medicines that have been ceased for this resident in the last 7 days? If ‘yes’ has the chart been signed and dated to indicate the cessation date? Has the DAA been returned to the pharmacy for repacking and/or bottle or packs of ceased medicines been removed from the drug trolley?
11. Are the required signatures present on all medication charts? 12. If medication has been refused or withheld has this been recorded appropriately? 13. Have all refused or withheld medicines (more than 7 consecutive doses) been referred to the doctor for review?
14. Has the pharmacy dispensed adequate stock of medicines to ensure that missed doses do
15. Is the resident’s current photo attached to the medication chart?
16. Has the drug refrigerator temperature been monitored? (please circle) Yes No
17. Have all open eye drops and Anginine etc., been marked with an opening date? (please circle) Yes No