Akinsola Oluwatosin, Nwachukwu Kingsley, Kavanagh Annette
Thomas Embling Hospital,Victoria,Australia.
Connolly Hospital,Blanchardstown,Dublin,Ireland.
Ir J Psychol Med. 2011 Jun;28(2):82-83. doi: 10.1017/S0790966700011484.
The survey was designed to evaluate the current prescribing practice of the doctors in our local psychiatric unit against the standards outlined by the National Health Office in the Code of Practice for Healthcare Records Management, and to assess the changes in practice by completing an audit cycle.
The survey was carried out in a 27 bed acute psychiatric unit. A single assessor reviewed 51 inpatient drug prescription charts using a standardised data collection form derived from the Code of Practice document. Results were presented to the relevant clinical staff and a repeat survey was conducted a few months afterwards. All data were categorical and the frequencies were computed using SPSS 13.0.
A total of 51 medication prescription charts were analysed on each occasion during the period of the study. The information contained on the drug charts were assessed against explicit predefined criteria as per the approved standard. At the initial survey, allergy documentation was absent in 59% of charts, only 18% of charts had generic only prescriptions, 90% of 'as required' medication lacked review dates, and only 33% of charts were considered to be reasonably neat. The repeat survey showed improvements in these practices, generic only prescribing increased to 39%, and 55% of charts were considered to be reasonably neat by the assessor.
Our study has identified deficiencies in prescribing practices and we have shown improvement in some of these practices at the repeat survey, however, further improvement is required. Given that the non-consultant hospital doctors are mostly involved in prescribing on drug charts, approved standards should be incorporated into the induction programme at the commencement of training in this unit. This standard should be monitored and maintained through the means of regular audits.
本次调查旨在对照国家卫生办公室在《医疗记录管理实践准则》中概述的标准，评估我们当地精神科病房医生当前的处方开具情况，并通过完成一个审计周期来评估实践中的变化。
调查在一个拥有27张床位的急性精神科病房进行。一名评估人员使用从《实践准则》文件衍生而来的标准化数据收集表，审查了51份住院患者的药物处方图表。结果反馈给了相关临床工作人员，并在几个月后进行了重复调查。所有数据均为分类数据，使用SPSS 13.0计算频率。
在研究期间的每次调查中，共分析了51份药物处方图表。根据批准的标准，对照明确预先定义的标准对药物图表上包含的信息进行评估。在初次调查时，59%的图表中没有过敏记录，只有18%的图表仅有通用名处方，90%的“按需”用药缺乏复查日期，只有33%的图表被认为书写较为工整。重复调查显示这些实践有了改进，仅开具通用名处方的比例增至39%，评估人员认为55%的图表书写较为工整。
我们的研究发现了处方开具实践中的不足之处，并且在重复调查中我们已经看到其中一些实践有了改进，然而，仍需要进一步改进。鉴于非顾问医院医生大多参与药物图表的处方开具，应在本单位培训开始时将批准的标准纳入入职培训计划。应通过定期审计的方式对该标准进行监测和维护。
