Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of care
against agreed and proven standards. The audit cycle includes the assessment of clinical management according to the standards of quality care and interventions then to re-measure the outcome to
make further improvements.
Aim of the audit is to identify & rectify the deficits and then improve. Monitoring , Assessment, Feedback, Discussion, Reassessment are important steps to make any improvement in medical management in healthcare organization.
The mistakes are bound to occur in situations where doctors are treating, reviewing the history, examining the patient as well as documenting the patient care. So, aim should be to improvise the process and not just the fault finding. Moreover, such audit should be done by the medical and para-medical professionals who are the stakeholders in medical management and understand the problems of the patient and doctors. So, medical audit or prescription audit is no way similar to financial audit. In prescription audit the standards should be according the evidence based medical practice. These standards should be achievable in that particular health care system.
The expected standards of an ideal prescription includes:
Prescription must contain the name of the patient , age and gender of the Patient.
Prescription card or note must be dated.
Prescription must be written in a legible manner where the dose, frequency and duration of treatment is clearly mentioned.
Each prescription must be signed by the doctor and doctors identity is clear.
The most common task done by doctors is the writing of prescription. This prescription bears the details of all the drugs including the instructions and name and signature of the physician. If not written appropriately it may loss to the patient including medication errors and adverse drug events
The doctors bears the legal responsibility for prescribing ethically and appropriately.
Prescription audit helps :
1. To prevent the practice of prescribing expensive, unnecessary , irrational and non-essential medicines by the physicians
2. To curtail the practice of writing costly branded drugs when the equally effective cheaper and generic drugs are available
3. To identify shortcomings in prescription writing
4. To reduce omissions in prescription writing by continuous evaluation and feedback to the doctors
5. To measure the extent to which information recorded on Out-Patient Card or In-Patient case file record sheet conforms to the guidelines for prescribing drugs. Prescription audit measures the compliance with standards set by the health care organization.
6. To articulate measures to improve prescription practices of the doctors.
7.To understand the pattern currently being followed by the doctors and include the drugs in hospital formulary.
The prescription audit improves the prescribing practice in any hospital. Audit is a valuable tool for monitoring compliance to prescribing and administration standards and for encouraging continued improvement in clinical practice.
Physicians, nursing professionals and pharmacists have an important role in continuous evaluation, feedback and improving the quality of health care.
Prescription audit is an important mechanism to improve the quality of healthcare and makes medical care affordable to everyone.