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National Inpatient Medication Chart (NIMC) Audit 2014

Analyzing examples from National Inpatient Medication Chart Audit 2014 to improve healthcare facility medication practices. Includes patient identification, weight documentation, adverse drug reactions, medication history, pharmaceutical review, and more.

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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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