Prescription Audit CH Ambala City February 2023

District Civil Hospital Ambala City

Prescription Audit Form

Name of Doctor conducting audit……………………………………………………………………

Prescription Number…………………………………………………………………………………

Date: …………………………………………………………………………………………………

S.No. Criteria Remarks

1. OPD Registration Number mentioned? Yes/No
2. Complete Name of the patient is written? Yes/No
3. Age in years (≥ 5 in years) in case of < 5 years (in months) Yes/No
4. Weight in Kg (only patients of pediatric age group) Yes/No
5. Complete address of the patient is mentioned Yes/No
6. Date of consultation - day / month / year Yes/No
7. Gender of the patient. Yes/No
8. Handwriting is Legible in Capital letter Yes/No
9. Brief history Written Yes/No
10. Allergy status mentioned Yes/No

11. Salient features of Clinical Examination recorded Yes/No

12. Presumptive / definitive diagnosis written Yes/No

13. Medicines are prescribed by generic names Yes/No

14. Medicines prescribed are in line with STG. Yes/No

15. Medicine Schedule / doses clearly written Yes/No

16. Duration of treatment written Yes/No

17. Date of next visit (review) written Yes/No

18. In case of referral, the relevant clinical details and reason for referral given. Yes/No

19. Follow-up advise and precautions (do’s and don’ts) are recorded Yes/No

20. Prescription duly signed (legibly) Yes/No

21. Medicines Prescribed are as per EML/ Formulary Yes/No

22. Medicines advised are available in the dispensary Yes/No

23. Vitamins, Tonics or Enzymes prescribed? Yes/No

Prescription Audit CH Ambala City February 2023
24. Antibiotics prescribed? Yes/No

25. Antibiotics are prescribed as per facility’s Antibiotic Policy Yes/No

26. Investigations advised? Yes/No

27. Injections prescribed? Yes/No

28. Number of Medicines prescribed.

Signature of Doctor