6685 Appropriate documentation on drug charts following acute admission

Objectives At quarterly intervals, new doctors are rotated across hospitals in each deanery. Following this, the doctors undergo a 2-day period of induction where formal practices and trainings are delivered before active work begins. One of those trainings include prescription training for paediatric patients. This is to ensure that the quality of care provided to paediatric patients is not affected by the rotations. It became imperative to assess and monitor the prescribing practice of all doctors working in the paediatric department as it may provide insight into effectiveness of the induction program or consolidate positive practice. Objectives To assess appropriate documentation of vital details including pharmacological information, and legible documentation of prescriber identifiers on the drug charts of paediatric patients admitted in a District General Hospital. Methods The GMC Good Medical Practice Domain 1.19, 1.20 and 1.21 focuses on clear, accurate and legible documentation. On that premise, we proffered that All drug charts should contain addressograph; documented current or estimated weight; documented allergy and/or sensitivity status and legible prescriber identifiers. A retrospective review of admission records, drug charts of patients admitted to the ward from September to October 2022 was done. These included patients admitted from the paediatric emergency department, clinics, paediatric assessment unit or from home. 145 drug charts were reviewed and checked across the standards. Results 52% of drug charts had addressographs whereas 67% of drug charts had documented weights. 61% of drug charts had legible prescriber identifiers and 37% of drug charts had documented allergy and/or sensitivity on pages with active prescriptions. Conclusion The prescription practice was subpar when compared to standard. The poorest outcome was documented allergy/sensitivity status which poses significant risk to the child. A plan for formal training of doctors on prescription on a quarterly basis and provision of visual aids in prescription areas became an action point. Furthermore, development of a checklist for ward staff to ensure patients admitted across clinical areas have appropriately completed drug charts and the need to consider electronic prescribing were other action points. The practice would be re-audited to assess the effectiveness of intervention. References General Medical Council (2019) Good medical practice – professional standards https://gmc-uk.org/-/media/documents/good-medical-practice---english-20200128_pdf-51527435.pdf