Checklist template

Pharmacy manager self-audit

A ready-to-use checklist with 107 items in 6 sections, covering Dispensing, Inventory, Records, Staffing, Customer service, Compliance. Use it as-is in InspectLoop, or adapt it to your own standards in minutes.

  • 6 Sections
  • 107 Items
  • 84 Yes / No checks
  • 6 Scored ratings
  • 114 Points

Use this template How audits work

1. Dispensing 20 items

  1. Period covered by this self-audit Choice
    • Month
    • Quarter
    • Half-year
  2. Prescriptions pulled at random from this period and reviewed for this self-audit Number
  3. Every prescription reviewed shows which pharmacist performed the final verification Yes / No 1 pt
  4. Every prescription reviewed shows which technician entered it Yes / No 1 pt
  5. The drug, strength and directions on each label reviewed match the original prescription Yes / No 1 pt
  6. The scanned image or hard copy could be found for every prescription reviewed Yes / No 1 pt
  7. Each bottle and package was barcode-scanned at filling for the prescriptions reviewed Yes / No 1 pt
  8. Barcode scan overrides this period were reviewed by me and each has a stated reason Yes / No 1 pt
  9. Barcode scan overrides recorded in this period Number
  10. Drug interaction alerts overridden on the prescriptions reviewed have a pharmacist note Yes / No 1 pt
  11. Allergy information is filled in, or marked "no known allergies", in each patient profile reviewed Yes / No 1 pt
  12. Look-alike and sound-alike drugs are separated or flagged with shelf markers in the dispensary Yes / No 1 pt
  13. High-alert drugs (insulin, warfarin, methotrexate) among the prescriptions reviewed show the independent double check required by company procedure Yes / No 1 pt
  14. Easy-open caps were dispensed only where the patient's request is on file Yes / No 1 pt
  15. Compliance packs checked this period matched the patient's current medication list Yes / No 1 pt
  16. Each basket or tote in the filling workflow holds one patient's prescriptions only Yes / No 1 pt
  17. Dispensing errors and near misses of this period are entered in the incident system Yes / No 1 pt
  18. Dispensing errors that reached a patient in this period Number
  19. I discussed each error of this period with the staff involved Yes / No 1 pt
  20. Accuracy of the prescriptions reviewed Rating
    • No discrepancies 5 pts
    • Minor documentation gaps 3 pts
    • A labeling or drug discrepancy found 1 pt

2. Inventory 19 items

  1. The controlled substance perpetual inventory was reconciled on the company schedule in this period Yes / No 1 pt
  2. Date of the last full controlled substance count Date
  3. Discrepancies found in the controlled substance count were investigated and reported per company policy Yes / No 1 pt
  4. I counted 10 fast-moving drugs during this self-audit and compared the count with the on-hand quantity in the system Yes / No 1 pt
  5. Drugs out of the 10 counted whose on-hand quantity was wrong Number
  6. The monthly check for out-of-date stock was completed on the dispensary shelves Yes / No 1 pt
  7. Stock expiring within the window set by company policy carries a short-date sticker Yes / No 1 pt
  8. Out-of-date drugs are held in a marked bin apart from saleable stock Yes / No 1 pt
  9. A return to the reverse distributor or the wholesaler was shipped within the interval set by company policy Yes / No 1 pt
  10. Prescriptions not picked up are returned to stock within the number of days set by company policy Yes / No 1 pt
  11. Returned-to-stock vials are labeled with drug, strength, lot and expiry date Yes / No 1 pt
  12. Order quantities suggested by the system are reviewed by a person before the order is sent Yes / No 1 pt
  13. The wholesaler delivery is checked against the invoice on the day it arrives Yes / No 1 pt
  14. Invoices for controlled substances received in this period are signed and dated by the pharmacist who checked the delivery Yes / No 1 pt
  15. The refrigerator temperature was logged twice a day throughout this period Yes / No 1 pt
  16. Refrigerator temperature at the time of this self-audit (°F or °C) Number
  17. Each refrigerator temperature excursion of this period has a written action Yes / No 1 pt
  18. Each recall notice received in this period is signed off with the action taken Yes / No 1 pt
  19. Control of dispensary inventory in this period Rating
    • Counts accurate and tasks on schedule 5 pts
    • Some counts or tasks late 3 pts
    • Counts unreliable or tasks not done 1 pt

3. Records 17 items

  1. Prescription hard copies are filed in number order Yes / No 1 pt
  2. Prescription files for the retention period required by local regulation are on site or retrievable from storage Yes / No 1 pt
  3. Controlled substance records are kept separately and can be produced on request Yes / No 1 pt
  4. Signature or pickup logs exist for 10 pickups sampled from this period Yes / No 1 pt
  5. Counseling offers and refusals are documented as required by company policy Yes / No 1 pt
  6. Immunization records of this period were sent to the registry or the physician where required Yes / No 1 pt
  7. Each staff member has a personal system login Yes / No 1 pt
  8. I saw no shared password in use at the dispensary terminals during this self-audit Yes / No 1 pt
  9. The logins of employees who left in this period have been deactivated Yes / No 1 pt
  10. Paper with patient information goes into a locked shredding bin Yes / No 1 pt
  11. No label or printout showing patient information was found in the regular trash Yes / No 1 pt
  12. The daily controlled substance report or dispensing log is reviewed and signed by a pharmacist Yes / No 1 pt
  13. Third-party audit requests received in this period were answered by their deadline Yes / No 1 pt
  14. The pharmacy license and each pharmacist's license are posted or available as required Yes / No 1 pt
  15. Earliest expiry date among the licenses and permits posted Date
  16. The policy and procedure manual at the dispensary is the current version Yes / No 1 pt
  17. State of the pharmacy's records Rating
    • Complete and easy to retrieve 5 pts
    • Complete but slow to retrieve 3 pts
    • Gaps found 1 pt

4. Staffing 17 items

  1. The posted schedule covers every opening hour with a pharmacist Yes / No 1 pt
  2. The day with the most prescriptions in the last full week was also the day with the most technician hours scheduled Yes / No 1 pt
  3. Prescriptions filled per pharmacist hour in the last full week Number
  4. Pharmacist-to-technician ratios stayed within the limit set by local regulation on the schedules reviewed Yes / No 1 pt
  5. Each technician's registration or certification is current Yes / No 1 pt
  6. Each new hire of this period completed privacy training before handling patient information Yes / No 1 pt
  7. Annual mandatory training is complete for every dispensary employee Yes / No 1 pt
  8. Dispensary employees with overdue mandatory training Number
  9. Meal and rest breaks for pharmacists were taken as scheduled in the last full week Yes / No 1 pt
  10. Tasks assigned to technicians and assistants stay within what local regulation allows them to do Yes / No 1 pt
  11. A relief pharmacist orientation sheet (alarm codes, contacts, local procedures) is kept at the dispensary Yes / No 1 pt
  12. Notes are on file for a dispensary staff meeting I held in this period Yes / No 1 pt
  13. Date of the last dispensary staff meeting Date
  14. Each employee received feedback or a performance conversation on the company schedule Yes / No 1 pt
  15. Open positions have been reported to the district manager Yes / No 1 pt
  16. Overtime in this period was approved in advance Yes / No 1 pt
  17. Staffing compared with workload in this period Rating
    • Matched to workload 5 pts
    • Stretched at peak times 3 pts
    • Short-staffed most days 1 pt

5. Customer service 17 items

  1. Average wait quoted for a walk-in prescription at the time of this self-audit (minutes) Number
  2. Prescriptions promised for a given time today were ready at that time Yes / No 1 pt
  3. A patient arriving at the drop-off counter is acknowledged within 30 seconds, as observed during this self-audit Yes / No 1 pt
  4. The phone was answered within the number of rings set by company policy on 3 test calls Yes / No 1 pt
  5. The voicemail refill line was cleared at least twice today Yes / No 1 pt
  6. Patients are told when a prescription is partly filled and when the balance will be ready Yes / No 1 pt
  7. Balances owed to patients are filled within the time set by company policy Yes / No 1 pt
  8. Prescriptions currently owing a balance to patients Number
  9. I saw the pharmacist offer counseling on new prescriptions during this self-audit Yes / No 1 pt
  10. Counseling takes place where other customers cannot overhear Yes / No 1 pt
  11. Patients enrolled in automatic refills or text reminders are receiving them, checked on 3 profiles Yes / No 1 pt
  12. Each complaint received in this period was logged with its outcome Yes / No 1 pt
  13. Patient complaints logged in this period Number
  14. Prescriptions waiting for a prescriber's answer are followed up daily Yes / No 1 pt
  15. Signs for language assistance or an interpreter line are posted at the counter Yes / No 1 pt
  16. The will-call bins contain no prescription older than the limit set by company policy Yes / No 1 pt
  17. Service observed at the pharmacy counter Rating
    • Prompt, private and courteous 5 pts
    • Courteous but slow or not private 3 pts
    • Patients ignored or kept waiting without explanation 1 pt

6. Compliance 17 items

  1. The last inspection report from the regulator is on file Yes / No 1 pt
  2. Every finding of the last regulatory inspection has been closed Yes / No 1 pt
  3. Date of the last inspection by the pharmacy regulator Date
  4. The privacy notice for patients is posted or available at the counter, as local regulation requires Yes / No 1 pt
  5. Privacy incidents of this period were reported per company policy Yes / No 1 pt
  6. Sales of products with purchase limits, such as pseudoephedrine, are logged as required by local regulation Yes / No 1 pt
  7. The controlled substance cabinet or safe was locked when I checked it Yes / No 1 pt
  8. I reviewed the list of people holding a key or code to the controlled substance cabinet or safe in this period, and each one is authorized by company policy Yes / No 1 pt
  9. The alarm codes of the dispensary were changed or reissued after the last departure of a code holder Yes / No 1 pt
  10. The dispensary is locked or closed off whenever no pharmacist is present Yes / No 1 pt
  11. Required reference texts or online references can be opened at the dispensary Yes / No 1 pt
  12. No sharps or pharmaceutical waste container is filled above its fill line Yes / No 1 pt
  13. Vaccine and injection protocols or standing orders are signed and in date Yes / No 1 pt
  14. The corrective actions from my previous self-audit are complete Yes / No 1 pt
  15. Name of the pharmacy manager completing this self-audit Short text
  16. Overall result of this self-audit Rating
    • No finding in any section 5 pts
    • Findings I can close before the next self-audit 3 pts
    • Findings that need district support to close 1 pt
  17. Actions I will take before the next self-audit, with target dates Comments

About this template

This checklist is part of the InspectLoop 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 InspectLoop you can add photos, assign corrective actions, require sign-off and compare results across sites.

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