Medication Follow-Up Audit Form
Audit and document medication administration and follow-up for quality assurance.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date and Time of Medication Administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Medication Details
*
Dosage Administered (mg, mL, etc.)
*
Route of Administration
*
Please Select
Oral
Intravenous (IV)
Intramuscular (IM)
Subcutaneous (SC)
Topical
Other
Medication Administration Compliance Check
*
Rows
Yes
No
Not Applicable
Right patient verified
1
2
3
Right medication verified
4
5
6
Right dose verified
7
8
9
Right route verified
10
11
12
Right time verified
13
14
15
Were there any adverse drug reactions or events?
*
No adverse events observed
Mild reaction (e.g., rash, nausea)
Severe reaction (e.g., anaphylaxis, hospitalization)
Other (please specify)
Describe any adverse drug reactions or events (if applicable)
Follow-Up Actions Taken
*
Physician notified
Medication stopped
Dose adjusted
Patient monitored
No further action required
Other (please specify)
Auditor/Staff Name
*
First Name
Last Name
Additional Comments or Observations
Signature of Auditor/Staff
*
Submit Audit
Submit Audit
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