Electronic Inpatient Medication Record (eIMR) System

_{Shared by Singapore Community Hospital (SCH). GKPS Reference: Electronic Inpatient Medication Record (eIMR) Audit Checklist. Global Knowledge Sharing Platform for Patient Safety (GKPS). 2023. A017.}

This checklist aims to strengthen the safety of medication management. The 12 audit focus areas on prescription and pharmacy verification are:

1. All orders must have a correct start date (e.g. EOD orders, colecalciferol after loading dose, step down dosing regimen)

2. All orders must include the frequency of administration (e.g. Q8h, Q6h, BD, TDS, etc)

3. The route of orders must be clearly indicated (e.g. PO, IV, PR, SC, etc)

4. 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)

5. All changes in drug/dose/frequency must be cancelled and re-ordered as a new entry.

6. 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.

7. All additional 'free text' remarks must be clear and concise. To remove unnecessary / irrelevant remarks as far as possible.

8. 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.

9. PRN orders : Ensure strength, frequency and indication are stated. (e.g. ketoprofen plaster bd prn for pain)

10. Use as directed' frequency is not recommended (except GTN tablet / spray)

11. Suspended orders : ensure reasons for suspension are stated

12. Future unsuspended orders : ensure correct date of unsuspension with reasons are stated

Actions to be taken or follow up will be monitored.