National Inpatient Medication Chart NIMC Audit 2014 Examples

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. 1. 2: Although patient ID label used, patient’s name not printed. Page 4 1. 3: No weight documented on NIMC or AORC.

Adverse Drug Reaction (ADR) Details

Adverse Drug Reaction (ADR) Details

Medication History 7 0 7

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

Venous Thromboembolism (VTE) Prophylaxis

Warfarin 0 Warfarin section not relevant to WA. 6. 1: Select NA 6. 2: Enter “ 0”

Sustained Release 2 2

Intermittent Medications 0 Nil Intermittent medications for this patient.

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.

Pharmaceutical Review

Prescribing and Administration

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

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

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

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

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

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 (Q 1 H) 11. 7/8 (Dose calc’n) : NA 11. 9 (Abbr’n): Y (Q 1 H) 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

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’n doc’d): N 11. 8 (Dose calc’n doc’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

Questions and Discussion

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