1 Start 2 Day 1 3 Day 2 4 No Medications 5 Complete Instructions:Complete this survey for each client/resident using an identifier you can easily recognize without revealing personal health information. For example, use the room number or house address to keep track of which medication audits have been conducted. Complete audits in June and December. Site Name: * Be specific - if you are a part of a site with multiple locations, please specify which location you are reporting from. Month of Audit: * June December Name of person conducting audit: * Client/Resident Identifier * (Anonymized) Indicate if your client with PD or related movement disorder is taking any of the medications below: * Reglan (metoclopramide) Compazine (prochlorperazine) Asenden (amozapine) Haldol (haloperidol) Zyprexa (olanzapine) Risperdal (risperidone) Rexulti (brexpiprazole) Depakote (valproate) None of the Above Our agency does not routinely collect medication information. We administered Carbidopa / Levodopa Parkinson's medications to clients/residents during this audit period. * Yes No Leave this field blank
