Table 1 Descriptions for the eight targeted charting requirements
Charting Requirement | Further description |
|---|---|
Chart Number | The number of the NIMC in the sequence of active NIMCs is written on the front of the chart |
Patient Surname | Patient’s surname handwritten below the patient label |
Prescriber Name | A prescriber name was printed and legible (on at least one of the records on the page) for regular medication orders |
Dated and Signed | All regular medication orders were dated and signed |
Generic REG | All regular (REG) medication orders used a generic medication name rather than a brand name. Brand name exceptions: Movicol, Oxycontin, Endone, Fleet Enema |
Indication REG | An indication was recorded for some regular (REG) medications ie antibiotics, anticoagulants and steroids including eye drops and topical creams. |
Indication PRN | An indication was recorded for all Pro Re Nata (PRN, as needed) medications |
Max Dosage PRN | The maximum dose in 24 h was indicated for all PRN medications |