Documentation

Quality statement 6

When a patient is prescribed an antimicrobial, the indication, active ingredient, dose, frequency and route of administration, and the intended duration or review plan are documented in the patient’s healthcare record.

Purpose

To improve documentation of antimicrobial treatment to support effective communication among clinicians through the patient’s healthcare record. This record may include mechanisms such as paper or electronic healthcare records, the My Health Record system, prescription records or the medication chart. Documentation allows the appropriateness of the prescription to be assessed, and ensures that all clinicians involved in the patient’s care have access to consistent and current information.

 

For patients

Your healthcare record contains information about your antimicrobial therapy. This includes information on:

  • The medicines you have been prescribed (active ingredients)
  • Why they were prescribed and by whom
  • When they were prescribed
  • The dose
  • What form of the medicine you use (such as tablets or an injection)
  • How often you have them
  • How long to use them for 
  • Any plans to review your treatment.

For clinicians

When prescribing antimicrobials, document the indication, active ingredient, dose, frequency and route of administration, intended duration, and a review plan in the patient’s healthcare record. If required, document any plans for therapeutic drug monitoring.

For health service organisations

Ensure a system is in place so that when clinicians prescribe antimicrobials, they document the clinical reason, active ingredient, dose, frequency and route of administration, intended duration and a treatment review plan in the patient’s healthcare record. Where electronic healthcare records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

For patients

Your healthcare record contains information about your antimicrobial therapy. This includes information on:

  • The medicines you have been prescribed (active ingredients)
  • Why they were prescribed and by whom
  • When they were prescribed
  • The dose
  • What form of the medicine you use (such as tablets or an injection)
  • How often you have them
  • How long to use them for 
  • Any plans to review your treatment.

For clinicians

When prescribing antimicrobials, document the indication, active ingredient, dose, frequency and route of administration, intended duration, and a review plan in the patient’s healthcare record. If required, document any plans for therapeutic drug monitoring.

For health service organisations

Ensure a system is in place so that when clinicians prescribe antimicrobials, they document the clinical reason, active ingredient, dose, frequency and route of administration, intended duration and a treatment review plan in the patient’s healthcare record. Where electronic healthcare records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields.

Quality statement 6 has indicators for local monitoring.

Read Quality statement 7 - Review of therapy