| Date | Site of audit | Wards/departments included (not required) | Number of entries submitted in this audit | Number of items on this script | Number of drugs with trade (non-generic) names | Number of drugs without dosing and/or frequency | Number of drugs without route | Number of drugs with Greek/Latin abbreviations | Number of different prescribers on this script | Is each prescriber clearly identifiable? | Script signed? | Script dated? | Patient’s identifiers on script? | Folder number on script? | Allergy status documented? | How legible is the script as a whole? | Anything else observed? |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 26/01/2025 | CMH Wards | 10 |
2, 7, 3, 6, 5, 10, 7, 5, 5, 5 Total:55 |
0, 0, 0, 0, 0, 0, 0, 1, 0, 0 Total:1 |
0, 0, 0, 0, 0, 1, 0, 0, 0, 0 Total:1 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
1, 2, 1, 1, 2, 2, 1, 2, 1, 1 Total:14 |
Yes:9 No:1 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:0 No:10 |
Fully legible: 7 Few items difficult to read: 3 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
In this case under allergies nothing was written (indicating nothing), Once again allergy status not recorded (nothing is included in this section), Once again allergy status not documented, and in this note it was forgotten to put patient identifiers on the page with medication it was only visible at the back, Certain medications were slightly hard to read as well as their route and once again allergy status not documented, Once again allergy status left blank and no note put for it, Clotrimazole cream topically for 12 hours but the dose of the cream was not given , allergy status not reordered and folder number on the front not included but included at the back(all said was clotrimazole cream 190-the tube they using in word is clotrimazole 10mg/g), Once again allergy status left blank nothing noted as to if patient has allergies or none, Allergy status not stated, furthermore one of the prescribers although signed it is illegible as to who this doctor is registration number is not really legible, also slow k was written instead of potassium chloride, Once again allergy status not documented, Folder number not present on front of script but present at the back and allergy status not documented | |
| 22/01/2025 | CMH MOPD | 1 |
10 Total:10 |
2 Total:2 |
0 Total:0 |
2 Total:2 |
7 Total:7 |
3 Total:3 |
Yes:0 No:1 |
Yes:1 No:0 |
Yes:1 No:0 |
Yes:0 No:1 |
Yes:0 No:1 |
Yes:0 No:1 |
Fully legible: 0 Few items difficult to read: 1 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
||
| 06/11/2024 | CMH Wards | G1, G2, G3, G5 | 12 |
9, 7, 5, 6, 6, 5, 4, 6, 9, 2, 8, 3 Total:70 |
0, 0, 0, 0, 0, 1, 0, 1, 0, 0, 1, 0 Total:3 |
0, 0, 0, 0, 0, 0, 0, 1, 0, 0, 1, 0 Total:2 |
0, 0, 0, 0, 0, 0, 0, 1, 0, 0, 1, 0 Total:2 |
0, 0, 0, 0, 0, 0, 1, 0, 0, 0, 0, 0 Total:1 |
5, 1, 2, 2, 2, 2, 1, 2, 1, 1, 3, 1 Total:23 |
Yes:4 No:8 |
Yes:10 No:2 |
Yes:12 No:0 |
Yes:10 No:2 |
Yes:10 No:2 |
Yes:2 No:10 |
Fully legible: 10 Few items difficult to read: 1 Somewhat legible: 1 Mostly difficult to read: 0 Completely illegible: 0 |
Duplicated prescriptions, No working diagnosis, No working diagnosis |
| 25/07/2024 | CMH MOPD | 22 |
6, 4, 10, 7, 5, 3, 5, 6, 11, 9, 7, 4, 5, 5, 11, 4, 7, 2, 5, 11, 2, 9 Total:138 |
1, 0, 1, 0, 0, 0, 0, 1, 2, 0, 1, 0, 0, 1, 1, 0, 0, 0, 1, 1, 0, 0 Total:10 |
0, 0, 0, 0, 0, 0, 0, 0, 1, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:1 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 0, 0, 0 Total:2 |
0, 0, 1, 0, 0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 4, 0, 0, 0, 0, 0, 0, 0 Total:7 |
0, 0, 1, 0, 0, 0, 0, 1, 1, 0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 0, 0, 1 Total:6 |
Yes:22 No:0 |
Yes:21 No:1 |
Yes:21 No:1 |
Yes:22 No:0 |
Yes:12 No:10 |
Yes:11 No:11 |
Fully legible: 17 Few items difficult to read: 4 Somewhat legible: 1 Mostly difficult to read: 0 Completely illegible: 0 |
||
| 25/07/2024 | CMH MOPD | 15 |
6, 4, 10, 7, 5, 3, 5, 6, 11, 9, 7, 11, 11, 11, 10 Total:116 |
1, 0, 1, 0, 0, 0, 0, 1, 2, 0, 1, 0, 0, 1, 1 Total:8 |
0, 0, 0, 0, 0, 0, 0, 0, 1, 0, 0, 0, 0, 0, 0 Total:1 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 1, 0 Total:1 |
0, 0, 1, 0, 0, 0, 0, 0, 0, 2, 0, 1, 0, 2, 4 Total:10 |
0, 0, 1, 0, 0, 0, 0, 1, 1, 0, 0, 1, 0, 0, 0 Total:4 |
Yes:15 No:0 |
Yes:14 No:1 |
Yes:14 No:1 |
Yes:15 No:0 |
Yes:6 No:9 |
Yes:6 No:9 |
Fully legible: 11 Few items difficult to read: 4 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
||
| 25/07/2024 | CMH Wards | 26 |
11, 2, 5, 8, 6, 4, 6, 3, 3, 10, 7, 4, 2, 8, 4, 2, 9, 5, 11, 3, 6, 4, 6, 3, 1, 6 Total:139 |
0, 0, 1, 2, 1, 0, 1, 0, 1, 1, 0, 0, 0, 0, 0, 0, 1, 0, 0, 1, 0, 0, 1, 0, 0, 1 Total:11 |
0, 0, 0, 0, 0, 0, 0, 0, 1, 1, 0, 1, 0, 0, 1, 0, 2, 0, 0, 1, 0, 0, 1, 0, 0, 0 Total:8 |
0, 0, 0, 0, 1, 0, 0, 0, 1, 0, 0, 0, 0, 0, 1, 0, 1, 0, 0, 0, 0, 0, 1, 0, 0, 1 Total:6 |
0, 0, 1, 3, 0, 0, 0, 0, 0, 5, 0, 0, 0, 0, 1, 0, 1, 0, 0, 0, 0, 0, 1, 0, 0, 0 Total:12 |
1, 0, 1, 2, 0, 0, 0, 0, 0, 2, 0, 0, 0, 2, 1, 0, 2, 0, 0, 0, 0, 0, 1, 0, 0, 0 Total:12 |
Yes:24 No:2 |
Yes:25 No:1 |
Yes:26 No:0 |
Yes:26 No:0 |
Yes:20 No:6 |
Yes:13 No:13 |
Fully legible: 18 Few items difficult to read: 3 Somewhat legible: 4 Mostly difficult to read: 1 Completely illegible: 0 |
||
| 10/04/2024 | CMH MOPD | G1, G2, G3, G4, G5 | 10 |
5, 4, 6, 3, 10, 5, 5, 6, 3, 5 Total:52 |
0, 0, 0, 0, 1, 1, 0, 0, 0, 0 Total:2 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
2, 2, 3, 1, 2, 1, 1, 2, 1, 2 Total:17 |
Yes:9 No:1 |
Yes:9 No:1 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:9 No:1 |
Yes:3 No:7 |
Fully legible: 6 Few items difficult to read: 4 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
Antimicrobial section filled in but not fully. Medication given as prescribed. Front page filled out fully, 3 different handwriting only one signature. Only prescriber number for identification. Front page fully filled out. Antimicrobial section not filled in. Inner page identifiers not filled out. Medication given as prescribed. New script done with corrections and original script crossed out as there were many errors. Noticed day after admission, Antimicrobial section not filled in fully. Medication given as prescribed. Inappropriate comments written next to signature. Incorrect dosage noted by pharmacy and corrected. Diagnosis stated where appropriate. Only prescriber number for identification, Front page not filled in fully. Only name and folder number. Dosages and frequency changed but not fully crossed out therefore. Unclear if medication given as prescribed due to changes. Only prescriber number for identification, Medication not given as prescribed however many corrections to frequency and dosage not always written very clearly. Only prescriber number for identification. No year on dating of script for any medications. Where changes were made to dosage some were signed, Antimicrobial section not filled in. Medication given as prescribed. When corrections were made to dosage it was signed. Clearly stated second script and first script noted new script, Medication given as prescribed. Trade name written but in brackets generic name. Front page fully filled in, Antimicrobial section not filled in. Medication not given as prescribed. Incorrect frequency for 2 days. Only prescriber number for identification. Patient identifiers not written on inside of script. No year for date of any medications, Antimicrobial section not filled in. Bracket for signing by prescriber includes spaces not filled in and had not been scratched out. Medication given as prescribed, Antimicrobial section not filled in. Medication given as prescribed. Front page fully filled in. Only prescriber number for identification |
| 22/11/2023 | CMH Wards | G1, G 2 , G3 , G4 , G5 | 15 |
9, 3, 4, 3, 2, 3, 3, 8, 8, 5, 3, 5, 9, 7, 4 Total:76 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 1, 0, 0 Total:1 |
1, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:1 |
1, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:1 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
1, 2, 2, 1, 1, 1, 2, 2, 3, 2, 1, 2, 2, 1, 1 Total:24 |
Yes:8 No:7 |
Yes:15 No:0 |
Yes:15 No:0 |
Yes:15 No:0 |
Yes:15 No:0 |
Yes:2 No:13 |
Fully legible: 12 Few items difficult to read: 3 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
Patients identifiers not written on the inside of the script, Patient identifiers not written on the inside of the script, No date of birth written, No patient identifiers written on inside of script |
| 21/11/2023 | CMH Wards | G5 ,G3 | 10 |
8, 5, 4, 3, 5, 5, 1, 6, 7, 9 Total:53 |
0, 0, 0, 0, 1, 2, 0, 0, 0, 0 Total:3 |
1, 0, 0, 0, 0, 0, 0, 0, 2, 0 Total:3 |
1, 0, 0, 0, 0, 0, 0, 1, 1, 0 Total:3 |
1, 0, 0, 0, 2, 0, 0, 0, 0, 0 Total:3 |
1, 1, 2, 2, 2, 2, 1, 1, 1, 2 Total:15 |
Yes:3 No:7 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:1 No:9 |
Fully legible: 7 Few items difficult to read: 3 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
Ward not stated on script, Wrong ward written on script |
| 29/09/2023 | CMH Wards | 22 |
4, 5, 3, 4, 3, 6, 8, 5, 1, 7, 5, 8, 5, 4, 7, 6, 5, 7, 5, 7, 4, 9 Total:118 |
0, 0, 0, 0, 0, 0, 0, 0, 1, 1, 0, 1, 1, 0, 1, 1, 4, 1, 1, 0, 1, 0 Total:13 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 0 Total:2 |
0, 1, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 1, 0, 0, 0, 0, 0 Total:2 |
0, 3, 0, 0, 0, 0, 0, 0, 0, 0, 0, 2, 0, 0, 0, 0, 1, 0, 0, 0, 0, 0 Total:6 |
2, 3, 1, 1, 2, 3, 1, 1, 3, 3, 1, 4, 3, 1, 2, 1, 0, 1, 4, 3, 2, 3 Total:45 |
Yes:16 No:6 |
Yes:22 No:0 |
Yes:22 No:0 |
Yes:22 No:0 |
Yes:22 No:0 |
Yes:3 No:19 |
Fully legible: 18 Few items difficult to read: 4 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
||
| 14/09/2023 | CMH Wards | 1 |
3 Total:3 |
0 Total:0 |
0 Total:0 |
0 Total:0 |
1 Total:1 |
2 Total:2 |
Yes:0 No:1 |
Yes:1 No:0 |
Yes:1 No:0 |
Yes:1 No:0 |
Yes:1 No:0 |
Yes:1 No:0 |
Fully legible: 1 Few items difficult to read: 0 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
||
| 10/08/2023 | CMH Wards | 10 |
5, 4, 8, 5, 8, 5, 11, 4, 3, 6 Total:59 |
0, 0, 0, 0, 1, 1, 0, 0, 0, 0 Total:2 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 0, 1, 2, 3, 0, 0, 1 Total:7 |
1, 2, 4, 0, 3, 2, 1, 1, 1, 1 Total:16 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:10 No:0 |
Yes:5 No:5 |
Yes:3 No:7 |
Yes:2 No:8 |
Fully legible: 7 Few items difficult to read: 2 Somewhat legible: 1 Mostly difficult to read: 0 Completely illegible: 0 |
Gender of the patient circled, Gender of the patient not circled, Gender of the patient identified, Gender of the patient is identified, Gender of the patient is identified, Gender of the patient is identified, Gender of the patient is identified, Gender of the patient is identified, Gender of the patient is identified | |
| 17/05/2023 | CMH Wards | 11 |
6, 1, 5, 6, 6, 5, 7, 6, 7, 4, 4 Total:57 |
0, 0, 0, 2, 1, 0, 0, 2, 0, 0, 1 Total:6 |
0, 0, 0, 0, 0, 0, 0, 0, 0, 0, 0 Total:0 |
0, 0, 0, 1, 0, 0, 0, 0, 0, 0, 0 Total:1 |
1, 1, 1, 1, 0, 0, 0, 0, 1, 0, 1 Total:6 |
2, 1, 1, 1, 1, 2, 2, 1, 2, 2, 1 Total:16 |
Yes:7 No:4 |
Yes:11 No:0 |
Yes:11 No:0 |
Yes:10 No:1 |
Yes:9 No:2 |
Yes:0 No:0 |
Fully legible: 11 Few items difficult to read: 0 Somewhat legible: 0 Mostly difficult to read: 0 Completely illegible: 0 |
use of abbreviations when writing out medications |