Prescription chart writing practices in an acute psychiatric unit

Abstract

Objectives: 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.

Method: 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.

Results: 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.

Conclusion: 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.