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National Inpatient Medication Chart (NIMC) Audit 2014

National Inpatient Medication Chart (NIMC) Audit 2014. Examples to work through. Top of the front page. Healthcare Facility Code = Establishment ID. Patient Identification & Weight. 1. Page 3. 1.1: Only one NIMC currently in use.

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National Inpatient Medication Chart (NIMC) Audit 2014

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  1. National Inpatient Medication Chart (NIMC) Audit 2014 Examples to work through

  2. Top of the front page Healthcare Facility Code = Establishment ID

  3. Patient Identification & Weight 1 Page 3 1.1: Only one NIMC currently in use. 1.2: Although patient ID label used, patient’s name not printed. 1.3: No weight documented on NIMC or AORC. Page 4

  4. Adverse Drug Reaction (ADR) Details

  5. Adverse Drug Reaction (ADR) Details

  6. Medication History 7 0 7

  7. Variable Dose 0 Nil Variable Dose medication currently being used for the patient.

  8. Venous Thromboembolism (VTE) Prophylaxis

  9. Warfarin 0 Warfarin section not relevant to WA. 6.1: Select NA 6.2: Enter “0”

  10. Sustained Release 2 2

  11. Intermittent Medications 0 Nil Intermittent medications for this patient.

  12. Duplicate Orders Paracetamol SR tds regular + Paracetamol IR as PRN dose 1 Note the dates for the regular orders. They do not overlap, but the PRN order does.

  13. Pharmaceutical Review

  14. Prescribing and Administration

  15. 11.1 (Order No.): 1 11.2 (Drug Order): R 11.3 (Drug Name): C 11.4 (Route): C 11.5 (Dose): C 11.6 (Frequency): C 11.7/8 (Dose calc’n): NA 11.9 (Abbr’n): N 11.10 (Indication): N 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): Y 11.14 (Freq matches admin time): Y 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 10 11.18 (Doses admin’d): 9 11.19 (Max PRN dose): NA

  16. 11.1 (Order No.): 2 11.2 (Drug Order): R 11.3 (Drug Name): C 11.4 (Route): U (oral  “po”) 11.5 (Dose): C 11.6 (Frequency): C 11.7/8 (Dose calc’n): NA 11.9 (Abbr’n): N 11.10 (Indication): N 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): N (diff Dr) 11.14 (Freq matches admin time): Y 11.15 (Drug ceased): Y 11.16 (Drug ceased correctly): N (no date or reason) 11.17 (Doses req’d): 2 11.18 (Doses admin’d): 2 11.19 (Max PRN dose): NA

  17. Audit as “once daily” order: (unclear when dose has been changed) 11.1 (Order No.): 3 11.2 (Drug Order): R 11.3 (Drug Name): C or T (check site policy) 11.4 (Route): C 11.5 (Dose): C 11.6 (Frequency): U (“bd” was crossed off after PM dose given) 11.7/8 (Dose calc’n): NA 11.9 (Abbr’n): N 11.10 (Indication): N 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): Y 11.14 (Freq matches admin time): Y 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 10 11.18 (Doses admin’d): 9 11.19 (Max PRN dose): NA

  18. 11.1 (Order No.): 4 11.2 (Drug Order): P 11.3 (Drug Name): T 11.4 (Route): I (inh “inhale”) 11.5 (Dose): U (“i-ii”) 11.6 (Frequency): M 11.7/8 (Dose calc’n) : NA 11.9 (Abbr’n): N 11.10 (Indication): N 11.11 (P’cist Annotation): Y 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): N 11.14 (Freq matches admin time): NA 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 0 (as PRN) 11.18 (Doses admin’d): 0 (to match 11.17 even though doses given) 11.19 (Max PRN dose): N

  19. 11.1 (Order No.): 5 11.2 (Drug Order): S 11.3 (Drug Name): C 11.4 (Route): C 11.5 (Dose): C 11.6 (Frequency): NA 11.7/8 (Dose calc’n) : NA 11.9 (Abbr’n): N 11.10 (Indication): NA 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): N 11.14 (Freq matches admin time): NA 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 1 11.18 (Doses admin’d): 1 11.19 (Max PRN dose): NA

  20. 11.1 (Order No.): 6 11.2 (Drug Order): P 11.3 (Drug Name): C 11.4 (Route): U or C (PO/IV : check local policy) 11.5 (Dose): C 11.6 (Frequency): U (Q1H) 11.7/8 (Dose calc’n) : NA 11.9 (Abbr’n): Y (Q1H) 11.10 (Indication): Y 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): Y 11.14 (Freq matches admin time): NA 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 0 (PRN) 11.18 (Doses admin’d): 0 (to match 11.17) 11.19 (Max PRN dose): Y

  21. 11.1 (Order No.): 7 11.2 (Drug Order): P 11.3 (Drug Name): C 11.4 (Route): C 11.5 (Dose): C (calc based on paed dosing reference) 11.6 (Frequency): M (not documented in freq box) 11.7 (Dose calc’ndoc’d): N 11.8 (Dose calc’ndoc’d correctly) : N or NA 11.9 (Abbr’n): N 11.10 (Indication): N 11.11 (P’cist Annotation): N 11.12 (Pres. Signed): Y 11.13 (Pres. Clear): Y 11.14 (Freq matches admin time): NA 11.15 (Drug ceased): N 11.16 (Drug ceased correctly): NA 11.17 (Doses req’d): 0 11.18 (Doses admin’d): 0 11.19 (Max PRN dose): N

  22. Questions and Discussion

  23. Thank you for your time. Good luck with the auditing! If you have any queries, feel free to contact: Waiseen.Kee@health.wa.gov.au Kerry.Fitzsimons@health.wa.gov.au

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