Pediatric Weight-Based Dosing Verification Audit

Chart audit for pediatric medication orders to verify a documented kilogram weight is present and that ordered doses fall within approved maximum dosing limits.

Audit Details

• Patient identifier recorded on audit form
  Enter the chart or encounter identifier used for this audit. Do not enter full SSN or other unnecessary personal identifiers.
• Medication order date reviewed
  Record the date and time of the medication order or the chart review date, depending on audit workflow.
• Medication name documented for review
  Enter the medication being audited.
• Auditor notes
  Optional notes about the chart review context, exclusions, or follow-up needed.

Weight Documentation

• A current patient weight is documented in kilograms
  Verify the chart contains a documented weight in kilograms, not only pounds or an estimated weight.
• Weight source is clearly identified
  Confirm the chart identifies how the weight was obtained.
• Weight is recent enough for dosing decision
  Verify the documented weight is appropriate for the current encounter and medication order, per local policy.
• Weight conversion from pounds to kilograms is correctly documented, if applicable
  If the source weight was recorded in pounds, confirm the kilogram conversion is present and appears reasonable.

Dose Calculation and Maximum Limit Check

• Ordered dose is calculated using documented kilogram weight
  Verify the order, MAR, or pharmacist verification shows the dose was derived from the documented kilogram weight.
• Ordered dose is within the approved maximum dose limit
  Compare the ordered dose to the facility-approved or reference maximum dose for the medication and indication.
• Dose calculation is documented or independently verifiable
  Confirm the chart contains a calculation, pharmacist verification, or other traceable method that supports the final dose.
• Any dose rounding remains within safe limits
  If the dose was rounded for formulation or administration practicality, verify the rounded dose still falls within acceptable limits.

Order Safety and Escalation

• High-alert or narrow-therapeutic-index medication received independent double-check when required
  Verify a second clinician or pharmacist verification is documented when required by policy for the medication class.
• Any discrepancy was escalated and resolved before administration
  Confirm dose, weight, or indication discrepancies were addressed before the medication was administered.
• Prescriber or pharmacist clarification documented when dose exceeded limit
  If the initial order exceeded the maximum dose limit, verify there is documentation of clarification, correction, or override rationale.