National Inpatient Medication Chart User Guide

including paediatric versions

 Commonwealth of Australia 2012 This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. Requests and inquiries concerning reproduction and rights for purposes other than those indicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care, GPO Box 5480 Sydney NSW 2001 or mail@safetyandquality.gov.au Suggested citation Australian Commission on Safety and Quality in Health Care (2009), National Inpatient Medication Chart User Guide. ACSQHC, Sydney. Acknowledgment Many individuals and organisations have freely given their time, expertise and documentation to develop the NIMC User Guide. In particular, ACSQHC wishes to acknowledge the work of Queensland Healths Safe Medication Management Unit for its original work in developing the NIMC and support materials. ACSQHC also wishes to acknowledge members of the Health Services Medication Advisory Group (formerly the National Inpatient Medication Chart Oversight Committee) for their significant contribution to this document. Finally, ACSQHC also acknowledges all the users of the NIMC that suggest improvements and participate in audits, all of which contribute to maintenance of the NIMC User Guide. The involvement and willingness of all concerned to share their experience and expertise is greatly appreciated.

National Inpatient Medication Chart User Guide January 2012

Table of contents
1. Purpose 2. General instructions 3. Front page of the NIMC (including top section of page 3) 3.1 Identification of the patient 3.2 Patient weight and height 3.3 Numbering of the NIMC 3.4 Additional (specialised) charts 3.5 Adverse drug reaction alerts 3.6 Once only, pre-medication, standing orders and nurse initiated medicines 3.7 Telephone orders 3.8 Medicines taken prior to admission 4. Second and third pages of the NIMC 4.1 Variable dose medicines ordering 4.2 Venous Thromboembolism prophylaxis 4.3 Warfarin ordering 4.4 Warfarin education record 4.5 Regular medicines a. Date b. Generic drug name c. Slow release box d. Route e. Dose f. Frequency and administration times g. Pharmacy h. Indication i. Doctor signature and print name 4.6 Limited duration and ceased medicines 4.7 Administration record 4.8 Reason for not administering 4.9 Pharmaceutical review 4.10 Discharge supply 5. Back page of NIMC 5.1 As required (PRN) medicines 6. Special features of Paediatric NIMC 6.1 Patient weight, date, height and body surface area 6.2 Gestational age at birth 6.3 Dose calculation 6.4 Administration of medicines 7. Appendices Appendix A: National terminology, abbreviations and symbols to be used In the prescribing and administering of medicines in Australian hospitals Appendix B: Guidelines for withholding medicines Appendix C: Ordering oral and enteral nutritional supplements on the NIMC Appendix D: Version Control 1 5 6 6 6 6 7 7 8 10 10 12 12 12 14 14 15

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National Inpatient Medication Chart User Guide January 2012

National Inpatient Medication Chart User Guide

Target Audience The National Inpatient Medication Chart User Guide is intended for all nursing, medical and pharmacy staff and administrative and allied health staff that are authorised to access and use patient medication charts. Exceptions The National Inpatient Medication Chart is intended to be used as a record of orders and administration of general medicines. Where they exist for more specialised purposes (such as intravenous fluids, anticoagulants, management of diabetes, palliative care and acute pain) separate, specific charts should be used.

1. Purpose
Consistent documentation allows accurate interpretation of orders The National Inpatient Medication Chart is an initiative of the Australian Commission on Safety and Quality in Health Care (ACSQHC). Research shows that many adverse events reported in Australian hospitals are associated with medications. Research also demonstrates that improvements to medication chart design can improve the safety of medication processes in hospitals. The National Inpatient Medication Chart (NIMC) was developed by a group of health care professionals (including nursing, medical and pharmacy staff and the private sector) from States and Territories across Australia who were involved in similar medication chart standardising projects within their own organisations. Australian Health Ministers required a common inpatient medication chart to be in use in all public hospitals by June 2006 to assist in standardisation and consistent documentation of medications. As demonstrated in ACSQHCs 2008 NIMC Quality Improvement Project, the NIMC is used in healthcare facilities nationally to reduce the risk of prescribing and administering error. In conjunction with other standardisations, it is a valuable precursor to the electronic health environment. The NIMC is intended to reflect best practice and assist clinicians in improving the steps in the medication management cycle for safer prescribing, dispensing and administering of medicines in order to minimise the risk of adverse medication events. The following are general requirements regarding use of the medication chart: All prescribers must order medicines for inpatients in accord with legislative requirements as required by State/Territory Health (Drugs and Poisons) Regulations; The NIMC is to be completed for all admitted patients and placed at the foot of the bed unless ward/unit procedures state otherwise; All medications should be reviewed regularly to identify potential drug interactions and to discontinue medicines that are no longer required; Specific ordering charts are required for specialised medication orders such as insulin, intravenous fluids, anticoagulants, parenteral cytotoxic and immunosuppressive agents, epidural and regional infusion and patient controlled analgesia.

NIMC long-stay version A long-stay version of the NIMC was developed for long-term, stable patients in acute care settings. For example, the NIMC long-stay version may be suitable for patients in spinal units and rehabilitation units. The NIMC long-stay version available on the Commission web site has 28.5 days of administration available although the number of administration days may be varied. The NIMC long-stay version does not have variable dose or VTE prophylaxis pre-printed sections. Hospitals will need to ensure policies are in place so that those, or other, specialist drug therapies are stepped down for patients transitioning from the NIMC to the NIMC long-stay version. Paediatric versions of the NIMC In 2008, Australian Health Ministers endorsed paediatric versions of the NIMC (short and long stay). The paediatric NIMCs have additional features that support safe prescribing in the paediatric population including neonates. These charts should be used for all children aged 12 years and less. Instructions on the use of the safety features specific to the paediatric NIMCs are outlined in Section 6 of this guide. Unless otherwise indicated the general guide in Sections 2 through to 5 also apply to the paediatric NIMCs.

2. General instructions
All orders are to be written legibly in ink No matter how accurate or complete an order is, it may be misinterpreted if it cannot be read. Water soluble ink (e.g. fountain pen) should not be used. Black ink is preferred. A medication order is valid only if the prescriber enters all the required items (See Section 4.4). All information, including drug names, should be printed. Only accepted abbreviations should be used. Dangerous abbreviations must be avoided (See Appendix A). A separate order is required for each medicine. No erasers or whiteout can be used. Orders MUST be rewritten if any changes are made, especially changes to dose and/or frequency. The patients current location should be clearly marked on the medication chart.

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3. Front page of the NIMC (including the top section of page 3)

3.1 Identification of the patient

A watermark has been placed on the Patient Identification Section as a reminder that a prescription is not valid unless the patients identifiers are present, that is: EITHER the current patient identification label; OR, as a minimum, the patient name, UR number, date of birth and gender written in legible print.

The first prescriber must print the patients name. This will reduce the risk of wrong identification label being placed on the chart. Medication orders cannot be administered if the prescriber does not document the patient identification. 3.2 Patient weight and height

This information should be documented in the space provided (as it is important clinical information and vital for confirming doses of certain medicines).

The weight MUST be documented for paediatric patients. Refer to Section 6.1 for additional information relevant to paediatric patients 3.3 Numbering of the NIMC

If more than one NIMC in use, then this must be indicated by entering the appropriate chart numbers e.g. Medication Chart 1 of 2. If additional charts are written, this information must to be updated.

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Additional (specialised) charts

When additional (specialised) charts are written, this should be indicated by placing a tick or cross in the space provided. 3.5 Adverse drug reaction alerts

Medical officers, nursing staff and pharmacists are required to complete Allergies and Adverse Drug Reactions (ADR) details for all patients. (Patients may be more familiar with the term allergy, than ADR, so this may be a better prompt). Once the information has been documented, the person documenting the information must sign, print their name and date the entry. If any information is added to this section after the initial interview, the person adding the information must document their initials in the designated area If the patient is not aware of any previous ADRs, then the Nil known box should be ticked and the person documenting the information must sign, print their name and date the entry. If a previous ADR exists, then the following steps must be completed: a) Document the following information in the space provided on the NIMC and in the patients medical notes: Name of drug/substance; Reaction details (e.g. rash, diarrhoea) and type of reaction (e.g. allergy, anaphylaxis); Date that reaction occurred (or approximate timeframe e.g. 20 years ago)

Note: This is the minimum information that should be documented. It is preferable also to document how the reaction was managed (e.g. withdraw & avoid offending agent) and the source of the information (e.g. patient self report, previous documentation in medical notes etc). b) Affix an ADR alert sticker to the front and back page of the NIMC in the spaces provided, if alert stickers are available in your facility.

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Once only, pre-medication and nurse initiated medicines

Once only, pre-medication, standing orders and nurse initiated medicines are to be documented in the: Once only, pre-medication and nurse initiated medicines section of the NIMC Once only medicines section of the paediatric NIMC.

Once only and pre-medication orders The following must be documented for once only and pre-medication orders: Date prescribed; Generic name of medicine; Route of administration (accepted abbreviations may be used, refer to Section 4.5 and Appendix A); Dose to be administered, and the basis for the dose calculation (e.g. mg/kg/dose) for Paediatric NIMC; Date and time medicine is to be administered; Prescribers signature and printed name; Initials of person that administers the medicine, and initials of a second person to document double checking of the dose on the Paediatric NIMC; and Time medicine administered.

Standing orders Standing orders should be documented as once only medicines in accordance with local hospital policy or guideline.

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Nurse initiated medicines Nurse initiated medicines are non-prescription medicines that may be administered by a registered nurse or midwife or delegated to an authorised enrolled nurse in non-life threatening situations without a prior written or telephone instruction from an authorised prescriber. The medicine must be listed on the hospitals approved list of Nurse Initiated Medicines and administered in accordance with hospital policy. Some hospitals do not permit nurse initiated medicines to be administered to paediatric patients. The following must be documented for nurse initiated medicines; Generic name of medicine; Route of administration (accepted abbreviations may be used, refer to Section 4.5 and Appendix A); Dose to be administered, and the basis for the dose calculation (e.g. mg/kg/dose) for Paediatric NIMC; Date and time medicine nurse initiated; Nurse initiator to sign and print name; Initials of person who administers the medicine, and initials of a second persons to document double checking of the dose on the Paediatric NIMC; and Time medicine is administered.

Local hospital policy or guideline will outline when nurses can initiate medicines and will specify a limitation on doses of nurse initiated medicines that can be given such as for one dose only or for a maximum of 24 hours only. Generally this applies to a limited list of unscheduled, Schedule 2 and Schedule 3 medicines. Typically this list includes: Simple analgesics; Laxatives; Antacids; Cough suppressants; Sublingual nitrates; Inhaled bronchodilators; Artificial tears; Sodium chloride 0.9% flush; and IV infusion to keep IV line(s) patent as per local policy.

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Telephone orders

Local hospital policy/guidelines will outline whether telephone orders are allowed and under what circumstances they are to be used. The following must be documented for telephone orders: Date prescribed; Generic name of medicine; Route of administration (accepted abbreviations may be used, refer to Section 4.5 and Appendix A) Dose to be administered; Frequency medicine is to be administered; Initials of two nursing staff to confirm the verbal order heard and double checked (see example above); Name of doctor giving verbal order; Time of administration; and Initials of person who administers the medicine

The telephone order MUST be signed and dated, or otherwise confirmed in writing by the prescriber, within 24 hours. 3.8 Medicines taken prior to admission

The admitting medical officer, a pharmacist or other clinician trained in medication history taking and documentation may complete this section. The following must be documented: A complete list of all medicines taken normally at home (prescription, non-prescription and complementary medicines) including drug identification details (generic name, strength and form), dose and frequency, and duration of therapy/when therapy started; Whether the patient has their own medicines with them; Whether the patient uses a dose administration aid (e.g. Webster Pack or other blister pack); Whether there is a preferred dosage form (e.g. suspension for paediatric patients);

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Contact details for patients community health providers (GP and Community Pharmacist); and Whether the patient usually receives assistance to administer/manage their medicines.

Any unintentional discrepancies between the medication history and the medication orders noted by the person documenting the medication history must be brought to the attention of the prescriber or attending medical officer. Note: The NIMC provides space for the minimum information that should be documented for medicines taken prior to admission. It is also helpful to document the indication for use and to use a checklist as a prompt to ensure a comprehensive history is obtained. Alternatively the medication history can be documented on the national Medication Management Plan (MMP) form. The medication history section of the NIMC should be cross referenced to the MMP form. The MMP form, MMP User Guide and other implementation resources are available from the Commissions web site at http://www.safetyandquality.gov.au/our-work/medication-safety/medication-reconciliation/nmmp/ Refer to local health service policy for more information about a comprehensive approach to documenting the patients medication history.

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4. Second and third pages of the NIMC

4.1 Variable dose medicines ordering (Not applicable to paediatric NIMCs)

This section has been formatted to facilitate ordering of medicines that require variable dosing based on laboratory test results or as a reducing protocol e.g. gentamicin and steroids. If these agents are ordered in the regular ordering section, then there is no designated area to record drug levels and if they are ordered in the once-only ordering section, the risk of omission errors is increased. For each day of therapy, the following information should be documented: Drug level results; and Time drug level taken. Dose; Prescribers initials; Initials of the person who administers the dose (written in the row beginning with Time to be given). Actual time of administration which may be different from the dose time (written in the Time given row).

For each dose, the following information must be documented:

If a patient requires a second variable dose medication, or twice daily dosing, prescribe in the regular section using the same format as in the Variable Dose Medication section. 4.2 Venous Thromboembolism prophylaxis (Not applicable to long stay or paediatric NIMCs) This section has been included for hospitals piloting the draft NIMC with a pre-printed VTE prophylaxis section.

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This VTE section has been formatted to prompt documentation of: VTE risk assessment; Contraindications to VTE prophylaxis; and Ordering of pharmacological and/or mechanical VTE prophylaxis medication if indicated.

The section is placed adjacent to the warfarin section to assist with the recognition of patients who are already receiving therapeutic anticoagulation and do not require further VTE prophylaxis. Whoever has responsibility in the hospital for assessing the patients VTE risk should complete the VTE risk assessment according to local policy. The authorised clinician should sign and date in the risk assessment section that a VTE risk assessment has been done. Contraindication to VTE prophylaxis should be documented and the reason specified. In some hospitals documentation of the risk assessment will be done by the admitting medical officer/authorised prescriber. In other hospitals it will be the responsibility of the nursing staff. The risk assessment should be completed consistent with local hospital policy and in relation to the patients clinical status at that point. Reassessment of risk may need to occur depending on changes to clinical status, medicines and other circumstances. If the patient is at risk of VTE, and prophylaxis is not contraindicated, then the relevant prophylaxis should be prescribed in the corresponding section. Pharmacological VTE prophylaxis The prescriber should order the appropriate medication and specify: Route; Dose; Frequency; and Administration times.

Three dose time sections have been provided. This allows for anticoagulants to be administered up to three times a day. The indication section has been pre-printed with VTE Prophylaxis. If the dose of VTE prophylaxis medication needs to be changed, a new prescription should be prescribed on a subsequent chart. Mechanical VTE prophylaxis If the patient requires mechanical prophylaxis the authorised clinician should specify the type of mechanical prophylaxis required eg. graduated compression stockings (GCS) and provide their name, signature and contact details. Nursing staff may have responsibility for ordering mechanical prophylaxis depending on local hospital policy. In the mechanical prophylaxis section, AM and PM have been pre-printed in the dose time sections to encourage nursing staff to check and document that patients are receiving their mechanical prophylaxis. VTE treatment If VTE treatment is required, e.g. for a pre-existing DVT it should be ordered in the regular medication section and not in the VTE prophylaxis section.

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4.3

Warfarin ordering (Not applicable to Paediatric NIMC)

The warfarin ordering section is printed in red as an extra alert to indicate that it is an anticoagulant (and a high-risk medicine). It is recommended that a copy of guidelines for anticoagulation using warfarin is available to assist the prescriber/pharmacist/nurse when a patient is commenced on warfarin. The guidelines should offer information about target INR, duration of therapy, dosing, management of excessive bleeding and drug interactions. A standard dose time of 1600 hours (4pm) is recommended as this allows the medical team caring for the patient to order the next dose based on INR results, rather than leaving it for afterhours staff to do. The indication and target INR (based on guidelines for anticoagulation using warfarin) should be included when warfarin is initially ordered. For each day of therapy, the following information should be documented: 4.4 INR result; Warfarin dose; Prescribers initials; Initials of nurse that administers the dose and the checking nurse. Warfarin education record

Because of the well documented risks associated with use of warfarin, all patients should receive counselling about the use of warfarin and given written information on warfarin e.g. a warfarin book. This section is included as a record that these risk mitigation activities have been completed.

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4.5

Regular medicines (For paediatric NIMCs, also see section 6.3)

A medication order is valid only if the prescriber enters all listed items. a) Date - The date that the medication order was written should be entered. It is not the date that the medication was originally ordered. The prescriber will need to locate the original date of order if required. b) Generic Drug Name - Because there may be several brands of one agent available, the generic name should be used if possible unless combination preparations are being ordered (e.g. Timentin, Panadeine etc). Generally the pharmacy department will stock and supply only one brand of each generic drug. c) Red Tick if Slow Release box is included as a prompt to prescribers to consider whether or not the standard release form of the drug is required. This box must be ticked to indicate a sustained, modified or controlled release form of an oral drug (e.g. verapamil SR, Diltiazem CD). If not ticked, then it is assumed that the standard release form is to be administered. Further explanation as below is in the margin of the NIMC.

d) Route - Only commonly used and understood abbreviations should be used to indicate the route of administration. Acceptable abbreviations are listed below. The National Terminology, Abbreviations and Symbols to be used in the Prescribing and Administering of Medicines in Australian Hospitals (the National Terminology) forms Attachment A to this document. It provides principles for consistent prescribing terminology, a set of recommended terms and acceptable abbreviation and a list of error prone abbreviations, symbols and dose designations that have a history of causing error and must be avoided. Refer to it as the primary information source on terminology, abbreviations and symbols. The following advice is drawn from that document.
Commonly used and understood abbreviations Abbreviation Meaning PO per oral NG nasogastric subling sublingual IV intravenous IM intramuscular subcut subcutaneous PR per rectum PV per vagina eye drop eye drop eye ointment eye ointment topical topical MA metered aerosol Neb nebulised / nebuliser

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Abbreviation to avoid E or e

Dangerous abbreviations Not to be used Intended meaning Reason for avoiding ear or eye Misinterpreted as the other organ

Acceptable alternative ear or eye and specify whether left or right or both subcut or subcutaneous subling or sublingual

SC SL or S/L

subcutaneous sublingual

Mistaken for sublingual Mistaken for SC and interpreted as subcutaneous

e) Dose For the paediatric NIMCs, also see Section 6.3 Doses must be written using metric and Arabic (1,2,3) systems. Never use Roman numerals (i, ii, iii, iv). Acceptable abbreviations are listed below. Always use zero (0.) before a decimal point (e.g. 0.5g) otherwise the decimal point may be missed. However if possible it is preferable to state the dose in whole numbers, not decimals (e.g. Write 500mg instead of 0.5g or write 125microgram instead of 0.125mg). Never use a trailing zero (.0) as it may be misread if the decimal point is missed (e.g. 1.0 misread as 10) Do not use U or IU for units because it may be misread as zero. Always write units in full. Note In the case of liquid medicines, the strength and the dose in milligrams or micrograms (not millilitres) must always be specified e.g. morphine mixture (10mg/mL) Give 10mg every 8 hours Note The ward/clinical pharmacist will clarify when the strength supplied is different from that ordered e.g. For 10mg, the pharmacist may write 2 x 5mg tablets or for 25mg, the pharmacist may write half a 50mg tablet
Commonly used and understood abbreviations Abbreviation Meaning mL millilitre g gram mg milligram microgram or microg microgram mmol millimole Dangerous abbreviations Not to be used Reason for avoiding Intended meaning microgram Mistaken for milligram when handwritten unit Mistaken as the numbers 0 or 4, causing a 10-fold overdose or greater (e.g. 4U seen as 40 or 4u seen as 44). Mistaken for iv (intravenous) International Unit or as 31u (thirty-one units) 0.5mg Misread as 5mg

Abbreviation to avoid Ug, mcg or g U or u

Acceptable alternative microgram or microg unit(s)

IU or iu (e.g. 3 IU) No zero before decimal point (e.g. .5mg) Trailing zero after decimal point (e.g. 5.0mg)

International unit 0.5 mg or write 500 microgram or 500 microg Do not use trailing zero after decimal points after whole numbers

5mg

Misread as 50mg

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f)

Frequency and administration times. The prescriber writing the order must enter the frequency and administration time(s) when writing the medication order. This will prevent errors where the nurse misinterprets the frequency and writes down the wrong times. If these details are not entered, the dose may not be administered by nursing staff. Acceptable abbreviations are listed below. Times should be entered using the 24-clock (this nomenclature is the global standard). Drugs should be administered according to the Recommended Administration Times unless they must be given at specific times (e.g. some antibiotics, with/before food) or, as in the case of young children with variable meal and sleep schedules, a specific schedule is required.

Recommended administration times: Guidelines only Morning mane 0800 Night nocte 1800 or 2000 Twice a day bd 0800 2000 Three times a day tds 0800 1400 2000 Antibiotic 6 hourly 6 hrly 0600 1200 1800 2400 Antibiotic 8 hourly 8 hrly 0600 1400 2200 Four times a day qid 0600 1200 1800 2200

If necessary, the ward/clinical pharmacist or nurse will clarify (and annotate the chart) the administration time to correctly administer the drug (e.g. in relation to food).

Commonly used and understood abbreviations Abbreviation Meaning mane Morning nocte Night bd Twice daily tds Three times a day qid Four times a day unit(s) International Unit(s) Dangerous abbreviations - Not to be used Intended meaning Reason for avoiding Once a day Once daily Every day Morning Night Every six hours For one day For 3 days Mistaken for twice a day d is easily missed Mistaken as qid (four times a day) Mistaken for n (night) Mistaken for m (morning) Mistaken for six times a day Mistaken for one week Mistaken as for three doses

Abbreviation to avoid OD, od or d

Acceptable alternative daily or the specific time

QD or qd M N 6/24 1/7 X 3d

daily morning or mane night or nocte every 6 hrs or 6 hourly or 6 hrly for one day only for 3 days

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g) Pharmacy. This section is for use by the ward/clinical pharmacist to clarify the order, indicate source of supply or provide administration instructions. Annotations include: I for medicines available on imprest; S for non-imprest items that will be supplied and labelled for individual use from the pharmacy; Pts own for medicines checked by the pharmacist and confirmed to be acceptable for use during the patients admission; CD to indicate a Schedule 8 medicine (stored in CD cupboard); and Fridge to indicate a medicine that is stored in the fridge h) Indication This section is for the prescriber to document the indication. This allows the order to be reviewed in the context of why the medicine was prescribed, reducing the risk of misinterpretation of the order (e.g. medicines with look-a-like names) or incorrect doses (e.g. where medicines have different doses for different indications). i) Prescriber Signature and Print Name. The signature of the prescriber must be written to complete each medication order. For each signature (prescriber), their name must be written in print at least once on the medication chart. Limited duration and ceased medicines

4.6

When a medicine is ordered for a limited duration, or only on certain days, this must be clearly indicated using crosses (X) to block out day/times when the drug is NOT to be given

When stopping a medicine, the original order must not be obliterated. The prescriber must draw a clear line through the order in both the prescription and the administration record sections, taking care that the line does not impinge on other orders. The prescriber must write the reason for changing the order (e.g. cease, written in error, increased dose etc), the date and their initials in the administration record section. Note the acronym D/C should not be used for ceased orders since this can be confused with Discharge. Always use Cease.

When a medication order needs to be changed, the prescriber must not over write the order. The original order must be ceased and a new order written.

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4.7

Administration record

For the paediatric NIMCs, also see Section 6.3 The medication administration record provides space to record up to eleven days of therapy. At the end of eleven days, a new chart should be written. The last column (which is partially blocked out) is present only as a safety net if the order has not been rewritten. If the medication chart is full, then the medication orders written in it should not be considered valid/current prescriptions. The shading of alternate columns is intended to reduce the risk of administering a drug on the wrong day.

4.8

Reasons for not administering

When it is not possible to administer the prescribed medicine, the reason for not administering must be recorded by entering the appropriate code (refer below) and circling. By circling the code it will not accidentally be misread as someones initials. If a patient refuses medicine(s), then the prescriber must be notified. If medicine(s) are withheld, the reason must be documented in the patients medical notes. If the medicine is not available on the ward, it is the nurses responsibility to notify the pharmacy and/or to obtain supply or to contact the prescriber to advise that the medicine ordered is not available. (Refer to Appendix B: Guidelines for administering and withholding medicines)

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4.9

Pharmaceutical review

The clinical pharmacist will sign this section as a record that they have reviewed the medication chart (on that day) to ensure that all orders are clear, safe and appropriate for that individual patient.

4.10

Discharge supply

For each drug prescribed while an inpatient, the following information must be documented in the discharge supply section: Continue on discharge? Yes / No. Circle yes, if medication is to be continued on discharge Dispense? Yes / No. Circle yes, if the medication is to be dispensed by the hospital pharmacy on discharge. Duration days. Document number of days the medication is required on discharge. Qty.. Document quantity of the medication to be supplied.

For each page the following information is only required to be documented once: Prescribers signature Prescriber to print name Date discharge required Pharmacist signature Date discharge information completed

Jurisdictions may choose not to use this section for ordering the supply of medicines on discharge.

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5. Back page of the NIMC

5.1 As required (PRN) medicines

Prescribing The prescriber must write: Dose and hourly frequency. PRN (pre-printed) alone is not sufficient Indication and maximum daily dose (i.e. maximum dose in 24 hours) e.g. Paracetamol 4g

The Max dose/ 24 hours prompt indicates the total amount of the medicine which may be administered in 24 hours for PRN doses only. The maximum daily dosage should not be exceeded for that PRN medicine.

Prescribing PRN opioids The sedation score may be specified in the Max Dose/24 hrs section to indicate the maximum dose of drug to be administered when prescribing opioids in the PRN section. Where sedation scores are used the hospital policy or guideline should specify a standard sedation scoring system and a process for recording the scores, and the record must be available at the point of care. Nursing and medical staff should be familiar with the sedation scale used. In the example below, using the 4 point sedation scale of 0 to 3 published by the Victorian Quality Council (see below), the PRN order could specify if sedation score is less than 2. The error-prone symbol < should not be used.

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Sedation scale# 0 1 1s* 2 3 awake, alert mild sedation, easy to rouse asleep, easy to rouse moderate sedation, easy to rouse, unable to remain awake difficult to rouse

* may not be used in some centres where a score of 1 is used whether or not the patient is asleep as a sedation score of 2 could be missed.
#

Victorian Quality Council. (2007) Acute Pain Management Measurement Toolkit. From http://www.health.vic.gov.au/qualitycouncil/downloads/apmm_toolkit.pdf Accessed March 2012.

Prescribers should exercise caution when prescribing PRN medicines and check the regular medications section for possible duplicate orders. Administering The actual dose given must be recorded The person administering each dose is responsible for checking that the maximum daily dosage will not be exceeded.

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6. Special features of the paediatric NIMCs

The paediatric versions of the NIMC incorporate additional features identified as important for facilitating safe medicines use in the paediatric and neonatal populations. These features include designated: 6.1 Boxes for recording weight and date measured on front and back pages of chart; Spaces for recording body surface area and gestational age at birth (where relevant); Space for documenting the basis for dose calculation (e.g. mg/kg/dose); and Space for double signing when recording administration. Patient weight, date, height, and body surface area

The childs weight must be documented in the box on the front of the chart including the date weight was measured. The weight should also be documented on the back page when PRN medicines are ordered. The height and body surface area should be documented for when body surface area (BSA) is used to calculate the dose of a medicine. 6.2 Gestational age at birth

There is space for recording gestational age at birth under the BSA and height box. This should be completed for premature infants. 6.3 Dose calculation

The prescriber must document the basis for the dose calculation in the dose calculation box (e.g. mg/kg/dose or microgram/m2/dose etc). This will assist pharmacists, nurses and other doctors in double-checking the dose to ensure that the intended and actual dose is calculated correctly.

The basis for the dose calculation should first be checked in a current paediatric dosing reference endorsed by the local Drug and Therapeutics Committee. The actual dose should be calculated using an accurate weight or BSA (up to usual adult dose). If the child is obese or significantly oedematous, the ideal weight may be more appropriate. All calculations should be double-checked. 6.4 Administration of medicines

There are two spaces for recording the administration of each dose of medicine to allow for the recording of two signatures, to document that the double checking process has occurred when required.

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Appendix A

National terminology, abbreviations and symbols to be used in the prescribing and administering of medicines in Australian hospitals

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Appendix B: Guidelines for administering and withholding medicines

The NIMC is a legal document and therefore must be written in a clear, legible and unambiguous form. Every nurse has a responsibility to ensure they can clearly read and understand the order before administering any medicines. For all incomplete or unclear orders, the prescriber should be contacted to clarify. Never make any assumptions about the prescribers intent. Every medication chart must have the patients identification details completed. Every medication order must be complete and include: Date; Route; Generic drug name; Dose ordered in metric units & arabic numerals; Frequency (using only accepted abbreviations); Times (must be entered by the authorised prescriber); and Prescribers signature

If the medication chart is full (i.e. there is no appropriate space to sign for administration) then the medication order is not valid. The chart must be re-written as soon as possible. Withholding medicines It is appropriate to withhold the medicine if there is a known adverse drug reaction (ADR) to the prescribed medicine. Generally medicines should not be withheld if the patient is pre-operative or nil by mouth (NBM) / fasting unless specified by the authorised prescriber.

Remember the five Rs: The right drug The right dose The right route The right time The right patient

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Appendix C: Ordering oral and enteral nutritional supplements on the NIMC

The NIMC is not designed for ordering and recording administration of oral and enteral nutritional supplements. Its use for this purpose may result in: Confusion of nutritional supplements with medicines; (e.g. Pulmocare mistaken for the corticosteroid inhaler Pulmicort and amino acid liquid Nepro mistaken for the antiepileptic medication Keppra); Potential for patients to receive unauthorised medicines; and Delays in provision and administration of nutrition to patients if the NIMC is sent to the pharmacy for dispensing.

Some health services have a separate clinical nutrition chart for ordering and administration of nutritional products including nutritional supplements. An example of clinical nutrition chart is available on the Commission web site at http://www.safetyandquality.gov.au/ourwork/medication-safety/medication-chart/support-material/ Health services that choose to use the NIMC for ordering nutritional supplements should undertake a risk assessment and have a local policy or procedure on ordering and recording administration of nutritional supplements. The same requirements that apply to safer prescribing and administration of medicines on the NIMC should also apply to ordering and recording administration of nutritional products on the NIMC. Local policies or procedures for ordering and recording administration of nutritional supplements on the NIMC should include: Who is responsible for ordering nutritional supplement on the NIMC (medical officer, authorised dietitian, etc.); The requirement for a dietitian to undertake training in the key principles of safe prescribing practices before ordering an approved nutritional supplement on the NIMC; Where and how the nutritional supplement is ordered; The requirement to annotate nutritional supplement in the indication box or next to the product name; How to cease the nutritional product; Dietitian to regularly check NIMC for transcribing errors in nutritional product; and Regular auditing of prescriptions of nutritional supplements.

Example of a NIMC regular medication space used for ordering and recording administration of nutritional supplement

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Appendix D: Version control

Date 04/09/09

Version 1.1

Version title Guidelines for use of the National Inpatient Medication Chart including paediatric versions National Inpatient Medication Chart User Guide including Paediatric Versions National Inpatient Medication Chart User Guide including Paediatric Versions

Revision description

Author G. Bedford

18/08/10

1.2

G. Bedford

18/10/10

1.3

Expanded venous thromboembolism prophylaxis section Guidance on neonatal additions to paediatric NIMC and paediatric NIMC long-stay version Inclusion of Medication Management Plan Examples of settings for use of NIMC long-stay version Date of medication orders to be that for when the order is written or rewritten Max dose/24 hours definition changed to PRN doses only Variable dose section Instructions for administration signing Corrections

M. Duguid A. Wai

06/12/10

1.4

National Inpatient Medication Chart User Guide including paediatric versions January 2011

G. Bedford

31/01/11

1.5

National Inpatient Medication Chart User Guide including paediatric versions January 2011 National Inpatient Medication Chart User Guide including paediatric versions January 2011 National Inpatient Medication Chart User Guide including paediatric versions

G. Bedford M. Duguid G. Bedford

15/09/11

1.6

16/05/12

1.7

Standing orders and nurse-initiated medicines, Max dose/24 hours for PRN opioids VTE prophylaxis Ordering nutritional supplements on NIMC

G. Bedford M. Duguid A. Wai H. Stark

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