Audit in recording

Prescriptions
Aleena Athar
 Introduction
• Record keeping of prescriptions and the drugs that are being
prescribed is an important and often overlooked area.
• Ensuring to record all aspects of a patients treatment is
important

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 Aims
• The aim - evaluate if the recording of drug prescriptions was
accurate, up to date and if it was being recorded in all aspects of
clinical notes.
• The objective - ensure that accurate record keeping is being
carried out in line with GDC and CQC regulations on good
record keeping. A dental record should comprise of multiple
things but specifically to prescriptions, they must contain a
record of drugs prescribed/given including dosages together
with any adverse reactions

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 Method

1 2 3 4 5
Observed Sampling Additional Data gathering Launch
Current Practice Disseminate criteria included Foster holistically Deploy strategic
Synergize scalable standardized metrics Coordinate superior methodologies networks with
e-commerce compelling e-business
e-business applications needs

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 Results
Series 1 Series 2 Series 3 Series 1 Series 2 Series 3

2.0 3.0
Q1 2.4 Q3 1.8
4.3 3.5

2.0 5.0
Q2 4.4 Q4 2.8
2.5 4.5

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 Changes Implemented
Recording of prescriptions -Changed the prescription record
Previously included:
• Prescription no., Date, Patient name
Will now include:
• Prescription no., Date, Patient number, Pt DOB, Prescribing Clinician, Drug prescribed

Practice meeting
• Mentioned need to record if a prescription has been given, in both the clinical notes and
the treatment plan

12/19/2023 PRESENTATION TITLE 6

 Re-Audit
• The aim - evaluate if the implemented changes helped to improve the recording of drug
prescriptions
• The objective - ensure that accurate record keeping is being carried out in line with GDC
and CQC regulations on good record keeping. A dental record should comprise of
multiple things but specifically to prescriptions, they must contain a record of drugs
prescribed/given including dosages together with any adverse reactions

12/19/2023 PRESENTATION TITLE 7

 Timeline
Dec 2022 March 2023
Initial audit Re-Audit

Changes Implemented

Jan 2023

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 Conclusions

• Was much easier to carry out Re-audit

• Prescription logging as improved in log book as more accurate

• Prescription logging in notes and treatment plan has improved slightly

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Thank you