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Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 85-87

An audit of prescription forms of patients from obstetrics and gynecology clinics in tertiary care hospitals: An exploratory study

1 Department of Obstetrics and Gynaecology, Maulana Azad Medical College, New Delhi, India
2 Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India

Correspondence Address:
Dr. Neha Varun
A-2a/35, West Janakpuri, New Delhi - 110 058
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJMS.INJMS_157_19

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Objective: The main aim is to analyze the prescription forms to evaluate the completeness of these forms, and we also aim to bring to light the factors which need to be emphasized on while writing a prescription. Materials and Methods: This is a prospective cross-sectional study. Prescriptions of 200 patients visiting the gynecology and antenatal outpatient department (OPD) were evaluated using a specially designed questionnaire containing specific questions pertaining about OPD prescriptions, and a score of 0, 1, or 2 was allotted to each question. Results: In an audit of 200 OPD prescription papers, complete name, age, date of consultation, sex, and OPD registration number of the client were present in 100% prescriptions as it was preprinted. Legible handwriting was seen in 93%. Essential medicines advised were available in the hospital dispensary in 77%. Dosage schedule/doses were clearly written in 85%. Prescription duly signed and the name is written (legibly)/stamped in 87%. The highest score for a prescription was found to be 17/17 and the lowest score for a prescription form was 8/13. Conclusion: Many areas are lagging in prescription writing, especially writing presumptive diagnosis and salient features of clinical examination. Physicians need to improve their prescription writing skills for the benefit of patients.

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