Checklist template

Medication therapy and clinical services for pharmacies

A ready-to-use checklist with 109 items in 6 sections, covering Appointments, Private room, Documentation, Follow-up, Program targets, Patient feedback. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 109 Items
  • 87 Yes / No checks
  • 6 Scored ratings
  • 117 Points

Use this template How audits work

1. Appointments 17 items

  1. Clinical appointments (medication reviews, minor ailment assessments, point-of-care tests, smoking cessation) are booked in the company scheduling system Yes / No 1 pt
  2. Appointment slots are placed in hours when two pharmacists overlap or a second pharmacist is scheduled Yes / No 1 pt
  3. The dispensary stays covered by another pharmacist, or the workflow is paused as local regulation requires, while a consultation is in progress Yes / No 1 pt
  4. Patients receive a reminder call or text the day before their appointment Yes / No 1 pt
  5. The reminder asks patients to bring all their medicines, including non-prescription products and supplements Yes / No 1 pt
  6. Clinical appointments scheduled this week Number
  7. Clinical appointments completed last week Number
  8. Patients who missed their appointment last week Number
  9. Patients who missed an appointment are contacted to rebook within the time set by company policy Yes / No 1 pt
  10. The list of patients eligible for a medication review is pulled from the system or the payer platform every week Yes / No 1 pt
  11. Patients asking for a minor ailment assessment without an appointment are seen or booked on the same day Yes / No 1 pt
  12. The time reserved per appointment matches the company standard for the service Yes / No 1 pt
  13. The list of clinical services offered, with any fees, is available to patients at the counter Yes / No 1 pt
  14. The online booking link for clinical services opened and showed available times when tested Yes / No 1 pt
  15. An appointment observed or sampled started within 10 minutes of its scheduled time Yes / No 1 pt
  16. Telephone and video consultations are held from the consultation room, not from the dispensary counter Yes / No 1 pt
  17. Scheduling of clinical services Rating
    • Booked, reminded and started on time 5 pts
    • Booked with late starts or no reminders 3 pts
    • Done only when time allows, with no schedule 1 pt

2. Private room 20 items

  1. The consultation room has a door that closes Yes / No 1 pt
  2. A conversation at normal volume inside the room could not be followed from outside the door (tested by the inspector) Yes / No 1 pt
  3. The room is free of stored stock, totes and seasonal displays Yes / No 1 pt
  4. The room has seating for the patient and one companion Yes / No 1 pt
  5. A wheelchair can enter the room and turn Yes / No 1 pt
  6. A computer with access to the patient profile is in the room Yes / No 1 pt
  7. The computer in the room locks when the pharmacist leaves Yes / No 1 pt
  8. The blood pressure monitor in the room has a regular and a large cuff Yes / No 1 pt
  9. Quality-control checks of point-of-care testing devices are logged as the manufacturer requires Yes / No 1 pt
  10. Date of the last quality-control check of a point-of-care device Date
  11. Test strips and cartridges are within their expiry date Yes / No 1 pt
  12. Test strips and cartridges are stored within the temperature range on their label Yes / No 1 pt
  13. A sharps container for lancets is in the room, below its fill line Yes / No 1 pt
  14. Hand sanitizer is in the room, within reach of the pharmacist Yes / No 1 pt
  15. The table and chair arms are wiped with disinfectant between patients Yes / No 1 pt
  16. Placebo inhalers and demonstration injection pens are kept in the room Yes / No 1 pt
  17. Patient education leaflets in the room are current editions Yes / No 1 pt
  18. No patient record or printout from an earlier consultation is left in the room Yes / No 1 pt
  19. Certificates for additional authorizations (injections, prescribing) are displayed or on file for each pharmacist providing the service Yes / No 1 pt
  20. Readiness of the consultation room Rating
    • Private, equipped and clean 5 pts
    • Usable but shared with storage or missing equipment 3 pts
    • Not private or not usable 1 pt

3. Documentation 20 items

  1. Each of 5 consultations sampled was documented in the clinical platform on the day it took place Yes / No 1 pt
  2. The patient's consent to the service is recorded Yes / No 1 pt
  3. Consent to share the results with the patient's physician is recorded Yes / No 1 pt
  4. The medication list in each record includes non-prescription products and supplements Yes / No 1 pt
  5. Allergies and relevant medical conditions are recorded Yes / No 1 pt
  6. Each drug therapy problem identified is recorded with a recommendation Yes / No 1 pt
  7. The patient received a printed medication list or action plan at the end of the review Yes / No 1 pt
  8. The summary for the prescriber was sent on the same or the next business day Yes / No 1 pt
  9. A copy of what was sent to the prescriber is kept in the record Yes / No 1 pt
  10. Minor ailment assessments record the symptoms, the warning signs ruled out and the reason for the treatment chosen Yes / No 1 pt
  11. Point-of-care test results are recorded with the device used and the lot number of the strip or cartridge Yes / No 1 pt
  12. Patients with results outside the normal range were referred, and the referral is noted Yes / No 1 pt
  13. The pharmacist who provided the service is identified on each record Yes / No 1 pt
  14. The service billed matches the service documented in the records sampled Yes / No 1 pt
  15. Claims for clinical services are submitted within the payer's deadline Yes / No 1 pt
  16. Claims for clinical services rejected or reversed last month Number
  17. 3 records requested by the inspector were retrieved within 10 minutes Yes / No 1 pt
  18. A sample of clinical records is reviewed by a second pharmacist or the district clinical lead at least once a quarter Yes / No 1 pt
  19. Records sampled with complete documentation, out of 5 Number
  20. Quality of clinical documentation sampled Rating
    • Complete, timely and matched to billing 5 pts
    • Complete but late or brief 3 pts
    • Missing consent, problems or prescriber communication 1 pt

4. Follow-up 18 items

  1. Each drug therapy problem recorded has a follow-up date in the system Yes / No 1 pt
  2. Follow-ups due this week are listed in a queue or report Yes / No 1 pt
  3. Follow-ups overdue at the time of the visit Number
  4. Responses from prescribers to recommendations are tracked Yes / No 1 pt
  5. A recommendation without a reply is sent again after the number of days set by company policy Yes / No 1 pt
  6. Changes accepted by the prescriber are entered in the patient profile Yes / No 1 pt
  7. Discontinued medicines are inactivated in the profile and removed from automatic refill Yes / No 1 pt
  8. Patients starting a new long-term medicine receive a check-in call within the period set by company policy Yes / No 1 pt
  9. The late-refill report is worked every week Yes / No 1 pt
  10. Calls made from the late-refill report are documented in the patient profile Yes / No 1 pt
  11. Patients enrolled in refill synchronization are called before their monthly pickup date Yes / No 1 pt
  12. Patients treated for a minor ailment are followed up at the interval stated in the assessment Yes / No 1 pt
  13. Smoking cessation patients have their next visit booked before they leave Yes / No 1 pt
  14. For patients referred because of a high blood pressure or glucose reading, the record shows whether they saw their physician Yes / No 1 pt
  15. Three contact attempts are documented before a follow-up is closed as unreachable Yes / No 1 pt
  16. Medication lists of patients recently discharged from hospital are reconciled with the discharge prescriptions Yes / No 1 pt
  17. Each follow-up closed shows its outcome (resolved, ongoing, referred) Yes / No 1 pt
  18. Follow-up after clinical services Rating
    • Scheduled and completed on time 5 pts
    • Scheduled but often overdue 3 pts
    • No organized follow-up 1 pt

5. Program targets 17 items

  1. Targets of each clinical program for the current period are posted in the dispensary Yes / No 1 pt
  2. The pharmacy manager could state this month's target and the result to date Yes / No 1 pt
  3. Medication reviews completed this month Number
  4. Medication review target for this month Number
  5. Opportunities assigned by payers that were completed this period (%) Number
  6. Adherence score for the measures tracked by the store (%) Number
  7. Results are reviewed with the pharmacy team every week Yes / No 1 pt
  8. Results are shown by pharmacist Yes / No 1 pt
  9. No case in the payer platform queue expires this week without an attempt recorded Yes / No 1 pt
  10. Each program below target has a written action plan Yes / No 1 pt
  11. A technician asked could name two criteria that make a patient eligible for a medication review Yes / No 1 pt
  12. Each pharmacist providing a service has the training record for that service on file Yes / No 1 pt
  13. Pharmacist hours for clinical services are scheduled as the labor plan provides Yes / No 1 pt
  14. Counter signs or bag inserts for the current clinical campaign are in use Yes / No 1 pt
  15. Services launched on the company calendar this quarter are being offered at the store Yes / No 1 pt
  16. Actions from the last district manager visit on clinical services are completed Yes / No 1 pt
  17. Progress on clinical program targets Rating
    • On or above target 5 pts
    • Below target with an action plan 3 pts
    • Below target with no plan 1 pt

6. Patient feedback 17 items

  1. Patients are invited to complete a satisfaction survey after a clinical appointment Yes / No 1 pt
  2. The survey invitation contains no health information Yes / No 1 pt
  3. Survey responses received last quarter Number
  4. Average patient satisfaction score for clinical services (%) Number
  5. Survey results are shared with the pharmacy team Yes / No 1 pt
  6. Complaints about clinical services are recorded in the company system Yes / No 1 pt
  7. Complaints about clinical services last quarter Number
  8. Each complaint of the last quarter shows a reply to the patient Yes / No 1 pt
  9. The pharmacy manager could give one change made as a result of patient feedback Yes / No 1 pt
  10. A patient asked during the visit, with their agreement, could say what was recommended at their consultation Yes / No 1 pt
  11. Patients leave the appointment with a card or printout showing how to reach the pharmacist with questions Yes / No 1 pt
  12. Reasons given by patients who decline a clinical service are recorded Yes / No 1 pt
  13. Comments from prescribers about the pharmacy's recommendations are recorded Yes / No 1 pt
  14. Online reviews mentioning the pharmacy are answered as company policy requires Yes / No 1 pt
  15. Name of the pharmacy manager Short text
  16. Overall delivery of clinical services Rating
    • Organized, documented and valued by patients 5 pts
    • Delivered with gaps 3 pts
    • Rarely delivered or poorly documented 1 pt
  17. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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