Electronic Inpatient Medication Record (eIMR) System
|Electronic Inpatient Medication Record (eIMR) Audit Checklist||Shared by||Country|
|Mapped to Strategic Objective 3- Strategy 3.2 Download GKPSFILEA17||SingHealth Community Hospital (SCH)||Singapore|
This checklist aims to strengthen the safety of medication management. The 12 audit focus areas on prescription and pharmacy verification are:
- All orders must have a correct start date (e.g. EOD orders, colecalciferol after loading dose, step down dosing regimen)
- All orders must include the frequency of administration (e.g. Q8h, Q6h, BD, TDS, etc)
- The route of orders must be clearly indicated (e.g. PO, IV, PR, SC, etc)
- All orders must include the strength / quantity of the preparation especially for drugs ordered under “Other Medication” (e.g. 2g OM or 2 sachets OM)
- All changes in drug/dose/frequency must be cancelled and re-ordered as a new entry.
- The stop-date must not overlap with the start date of the new order for the same drug. Prescriber / pharmacist may future suspend order as needed.
- All additional ‘free text’ remarks must be clear and concise. To remove unnecessary / irrelevant remarks as far as possible.
- Drug administration device types must be included on the order, e.g. inhaler type (MDI, turbuhaler, accuhaler) and insulin type (vial, flexpen, penfill, etc), if applicable.
- PRN orders : Ensure strength, frequency and indication are stated. (e.g. ketoprofen plaster bd prn for pain)
- Use as directed’ frequency is not recommended (except GTN tablet / spray)
- Suspended orders : ensure reasons for suspension are stated
- Future unsuspended orders : ensure correct date of unsuspension with reasons are stated
Actions to be taken or follow up will be monitored.