SURBHI HOSPITAL IPD NO.

SNo. Criteria Points DATE

1 Does the medication chart(Drug chart) carries
Name
Age/Sex
IPD.No.
Does the patient UHID no. is being mention on the drug
chart
2 Was the Medication Chart
Clear
Legible
Dated
Time
Signed
Name and Reg No.of doctor
3 Is the Medication Chart clearly mentioned
Drug Name
Dosage
Frequency
Time
Route
Are all order of the medication being recorded on the
4 medication chart
5
Reconciliation of medications was done at the time initial
assessment.
6 Is the drug allergy noted in the drug chart
7 Is the drug allergy being considered while prescribing the
medication If no, is there any measure taken to rectify it .

8 Prescription are written in capital letters.

9 Prescription are written with generic names
10 Medication orders are written in uniform location
11 Are individual dosages mentioned in combination drugs?

12
Are any abbrevation being used in the drug chart?
13 Were verbal orders noted in this Chart ?
14
verbal orders are being counter signed within 24 hours?
15 Were any high risk medications given in this file?
16
Are the high risk orders countersigned by two nursing
staff?
17
Is there any therapeutic duplication in drug chart
18 Drug interaction being taken into consideration while
prescribing the medication .If no,is there any measure
taken to rectift if

19 Food drug interaction being taken into consideration

while prescribing the medication.
20 Medication error if any - Prescription error
any other
Auditor's Name & Sign SH/Qual/CHK/005/Ver 3.0/JUNE 19
 PERCENTAGE OF CRITERIA
TOTAL CRITERIA POINTS POINTS
 SURBHI HOSPITAL
OPD Prescription Audit
UHID NO.
DATE
SNo. Criteria Points
1 Does the prescription carries
Name
Age/Sex
UHID No
2 Was the prescription
Clear
Legible
Dated
Time
Signed
Name and Reg No.of doctor
3 Prescription clearly mentioned
Drug Name
Dosage
Frequency
Time
Route
4 Is the drug allergy noted
5 Is the drug allergy being considered while
prescribing the medication If no, is there
any measure taken to rectify it .
6 Prescription are written in capital letters.

7 Are individual dosages mentioned in

combination drugs?
8 Are any abbrevation being used in the
Prescription?
9 Is there any therapeutic duplication in
Prescription
10 Drug interaction being taken into
consideration while prescribing the
medication .If no,is there any measure
taken to rectift if

11 Food drug interaction being taken into

consideration while prescribing the
medication.
12 was diet advised according to healthcare
needs of the patient
13 Medication error if any -
Prescription error
any other
Auditor's Name & Sign SH/Qual/CHK/012/VER2/SEP/19
 SURBHI HOSPITAL
IPD Prescription audit IPD NO.
SNo. Criteria Points DATE

1 Does the medication prescription & administration record carries

Name
Age/Sex
UHID No
IPD.No.
2 Was the medication prescription & administration record
Clear
Legible
Dated
Time
Name and Reg No.of doctor
Sign of doctor
Is the medication prescription & administration record clearly
3 mentions
Drug Name
Dosage
Frequency
Time
Route
Are all order of the medication being recorded on the medication
4 prescription & administration record
5
Reconciliation of medications was done at the time initial
assessment.
6
Is the drug allergy noted in the medication prescription &
administration record
7 Is the drug allergy being considered while prescribing the
medication If no, is there any measure taken to rectify it .
8 Prescription are written in capital letters
9 Prescriptions are written in uniform location
10 Are individual dosages mentioned in combination drugs?
11 Are any abbrevation being used in the Prescription?
12 Were verbal orders noted in this Chart ?
13 verbal orders are being counter signed within 24 hours?
14 Were any high risk medications given in this file?
15 Are the high risk orders countersigned by two nursing staff?
16 Is there any therapeutic duplication in drug chart
17 Drug interaction being taken into consideration while prescribing
the medication .If no,is there any measure taken to rectift if
18 Food drug interaction being taken into consideration while
prescribing the medication.
19 Medication error if any - Prescription error
any other
Auditor's Name & Sign SH/104/PR/CHK-VER04/SEP-19
 PERCENTAGE OF CRITERIA
TOTAL CRITERIA POINTS POINTS
 SURBHI HOSPITAL SH/CA1/JAN/19

DATA COLLECTION SHEET

DATE

UHID

CRITERIA YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

Blood investigations done or not (fasting blood sugar,Random ,Hba1c

Blood sugar random charting done or not

insulin given or not ( 1. within TTP of insulin) (2. whether insulin given or not)

comorbidity illness managed or not

serum insulin sent or not

mnagement changed or not

patients with diabetes have b.p <130/80mmhg?

patients with diabetes have LDL levels <2.5mmol/L?

patients on diabetes have on statin therapy?

AUDITOR'S SIGN :