Prescription Audit in outpatient department of a district level government hospital in northern Kashmir: an observational study

Abstract

Background: An ‘audit’ is defined as ‘the review and the evaluation of the health care procedures and documentation for the purpose of comparing the quality of care which is provided, with the accepted standards’. Studying the prescription audit is that part of the audit which seeks to monitor, evaluate and if necessary, suggest modifications in the prescribing practices of medical practitioners.

Aims and objectives: In this study, we aimed to study the prescription pattern and assess the quality of prescription, with the standard prescription norms in Out Patient department of various specialities of a Government District Hospital.

Methodology: This observational study was conducted on the patients receiving medication during treatment in the outpatient departments of various specialities of the District Hospital, over a period of one month and the calculated sample size was 95 (according to the guidelines of prescription audit by MoHFW). An additional sample of 5 was included in the study, making the total sample size 100.

Results: A total of 20 parameters were assessed using a checklist. It was found that out of 100 study participants, brief history was mentioned in 51% prescriptions; dosage, duration and frequency was mentioned in 72% prescriptions, sign and stamp of the treating doctor was present on 37% prescriptions; medications were written in capital letters in 70% prescriptions, but were written in generic form in only 17% prescriptions. 78% of the medication orders were clear and readable; route of administration was not mentioned in 65% prescriptions. Vitamins, tonics or enzymes were prescribed in only 10% prescriptions, while antibiotics were prescribed in 44% prescriptions.

Conclusion: This study provides insights into prescription patterns and quality. By addressing the identified limitations and incorporating recommendations, healthcare providers can enhance the quality of prescriptions, leading to improved patient care and treatment outcomes in the outpatient setting.