Audit of outpatient prescription at a tertiary care hospital in South India: An observational study

Abstract

Background: Prescriptions are medico-legal documents and it is the duty of every physician to write a complete, legible, and valid prescription to ensure rational drug use and prevent the occurrence of medication errors. Periodic prescription audit is required for identification of common deficiencies in the prescriptions, to undertake corrective measures for improving the prescribing practices. Aim and Objective: The objective of the study was to assess the completeness of the outpatient hand-written prescriptions presented to the pharmacy of a multi-specialty tertiary care teaching hospital in South India. Materials and Methods: This was a prospective, descriptive cross-sectional study in which data from the outpatient prescriptions presented to the pharmacy for drug dispensing were recorded. The prescriptions were analyzed for completeness by assessing the presence or absence of the following essential components: (a) Date; (b) patient information (hospital registration number, name, age, gender, and address); (c) prescriber information (Name, Registration number, Signature); and (d) medication details (use of generic names, appropriateness of drugs, prescribing from national list of essential medicines [NLEM] 2015, capitalized drug names, dose, dosing schedule, route of administration, and instructions). Results: Of the total 600 prescriptions analyzed, all of them had date and complete patient details. Doctor’s name, registration number, and signature were mentioned in 70.8%, 38%, and 98.3% of prescriptions, respectively. About 30.3% and 26.8% of prescriptions had generic names and capitalized drug names, respectively. Only 2% of prescriptions were not legible. All the drugs prescribed were appropriate and from NLEM 2015. Dose and dosage schedule were clearly mentioned, each in 98% of prescriptions. Route of drug administration and instructions was present in 98.8% and 10% of prescriptions, respectively. Conclusion: This study showed that all the essential elements except doctors’ registration number, generic prescribing, drug names in capitals, and instructions to patient were present in majority of the prescriptions.