title: [Correct documentation of drug prescriptions].
abstract: The present study was undertaken to investigate and minimize possible differences in doctors' and nurses' documentation of drug prescriptions. A retrospective medical audit including 100 patients receiving medication revealed 69% correct prescriptions in doctors' case records. Only 44% of prescriptions in nurses' drug lists were correct. Based on the exposed problems a prescription sheet and clinical guidelines for medication were developed and implemented in the department. This resulted in 91% correct prescriptions in a comparable group of 100 patients receiving medication, a highly significant improvement. Among prescriptions signed by a doctor as legally requested, 98% were correct. The prescription sheet also served as an updated survey of medication. No health-threatening prescription errors were disclosed in either group. In conclusion, a common prescription sheet significantly improved the quality of drug prescriptions.
authors.affiliation: Vejle Sygehus, øre-naese-hals-afdelingen.
authors.forename: L P
authors.initials: LP
authors.lastname: Schousboe
authors.forename: O
authors.initials: O
authors.lastname: Tandrup
mesh_terms: D003718:Denmark; D004282:Documentation; D011307:Drug Prescriptions / Q000592:standards / Q000706:statistics & numerical data; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D008485:Medical Audit; D008508:Medication Errors / Q000517:prevention & control / Q000592:standards; D009726:Nurses; D010820:Physicians