PO ORDER AND ADMINISTRATION CHECKLIST

ORDER REVIEW
Patient identifiers checked in the clinical system:
Active order / prescriber / order date and time:
Medicine and exact formulation:
Tablet strength or liquid concentration:
Prescribed dose and corresponding tablet count or volume:
Prescribed route in full:
Schedule / one-time date and time / as-needed conditions and limits:
Reason for treatment:
Allergy check, relevant prior doses and sources checked:
Swallowing needs, oral-intake restrictions or formulation questions:

CLARIFICATION
Exact discrepancy or unanswered question:
Person contacted / time / actual response:
Confirmed instruction and authorizing clinician:
Order, label or record updated / time / remaining task:
Responsible person and agreed follow-up time:

ACTUAL ADMINISTRATION OR NON-ADMINISTRATION
Event date and time:
Medicine, formulation and amount actually given:
Actual route:
If not given: reason and action taken:
Observed event versus patient-reported information:
Administrator identification / authentication:

FOLLOW-UP
Reassessment planned / responsible person / agreed time:
Reassessment actually completed / time / findings:
Next action and owner:
Agreement between order, medication record and narrative checked: