Howell R R, Jones K W
McLeod Family Medicine Residency Program, Florence, SC.
Fam Med. 1993 Feb;25(2):104-6.
Duplicate prescription pads are used in many family practice residency programs to monitor prescribing patterns and detect errors in the actual prescription-writing process. This study looked at whether the review of duplicate prescriptions could be enhanced by adding the patient's diagnosis to the prescription.
The prescription-writing errors of Shaughnessy and Nickel were revised to include prescription-writing markers. These markers were defined as either an indication of use or a duration of therapy that differed from current medical literature or manufacturers' recommendations. Duplicate prescriptions of first-year family practice residents were reviewed for prescription-writing errors and markers before and after an in-service training regarding prescription writing.
Following the in-service training, the number of prescriptions containing the patient's diagnosis increased significantly (20% to 61%). Nineteen percent of all prescriptions contained prescription-writing errors. Eight percent of the prescriptions with the patient's diagnosis contained prescription-writing markers.
The addition of the patient's diagnosis to the prescription enhanced the review of duplicate prescriptions. It permitted the evaluation of not only the prescription-writing process but also the decision-making process that led to writing the prescription. It also permitted a more thorough evaluation of appropriate drug use.
许多家庭医学住院医师培训项目使用复写处方笺来监测处方模式，并在实际处方书写过程中发现错误。本研究探讨了在处方中添加患者诊断信息是否能加强对复写处方的审查。
对Shaughnessy和Nickel的处方书写错误进行修订，以纳入处方书写标记。这些标记被定义为与当前医学文献或制造商建议不同的使用指征或治疗持续时间。在进行关于处方书写的在职培训前后，对一年级家庭医学住院医师的复写处方进行审查，以查找处方书写错误和标记。
在职培训后，包含患者诊断信息的处方数量显著增加（从20%增至61%）。所有处方中有19%包含处方书写错误。有患者诊断信息的处方中有8%包含处方书写标记。
在处方中添加患者诊断信息加强了对复写处方的审查。这不仅允许评估处方书写过程，还能评估导致开具处方的决策过程。它还能对合理用药进行更全面的评估。
