Completion of Yellow Prescription Form in a Clinic File - Essay Example

?Running head: Completion of Yellow Prescription Form in a Clinic File Completion of Yellow Prescription Form in a Clinic File Rational for this Audit In order to ensure that ABC Clinic yellow prescription forms were appropriately completed, a compliance test was carried out with certain provisions of laws and regulations. This was necessary because, in every health institution, patients are usually given prescriptions that are followed while undergoing treatment (Carson, & Dent, 2007). Prescription forms are an essential tool since they determine the success of a treatment by monitoring the patient on-going treatment and condition. This makes the accuracy of the information very vital particularly for repeat and amended prescriptions. Prescription forms are also vital because they can be used as legal documents in case a patient is on any contraindicated medication. The documents can also be kept as reference information for further treatment. In an organization, record keeping is always regarded as a good practice, thus the prescription forms were as an important tool that can also be used to safeguard for herbal practice (Stamp & Moonitz, 1979). 2. Thoeoritical Back Ground In the health sector, most deaths are caused by errors that occur as patients undertake their medication. Research has indicated that more than 10% of the deaths occur because of patients not follow the doctor’s prescriptions. The health organizations like the American Heart Association (AHA) were forced to come together and form a scientific paper that would offer a proposal to enhance the well being of the patients. They achieved this by ensuring that the patients get proper prescriptions that were brief and accurate. In order to ensure that medical institutions executed this requirement, an audit was carried out for the ABC Clinic for four months (Nov1, 2012 -28th March, 2013). The audit was conducted in accordance with the acceptable health guidelines of the United States of America. The audit entailed the completion of yellow prescription form in clinic file for CAM treatment (herbal medicine), and other procedures that were regarded as important in the circumstances. In carrying out the audit on the prescription yellow forms, the audit aimed at ensuring the accuracy of information provided and use the same as a benchmark to ensure that the prescription met the required standards. The audit also aimed at ensuring that; the requirements for completion of the forms was reduced , most vital parts that had to be filed were identified, and to ensure that good medical practices were met ( Cascarino & Van esch, 2007). 3. Audit Criteria During the audit, the clinic was found to have a proper information system (Dauber, 2009). There were numerous prescription yellow forms, which were an indicator that the clinic had a well defined record keeping system. For convenience in our audit, a sample of 42 form samples was picked. Out of the 42 form samples, only2 samples had the CODE filled in. In terms of distinction of the forms, there were no clear distinction since the forms of the students and patients were similar in terms of color, thus making it possible for the forms to be easily mixed. The only distinction between the two forms was that the student sample contains fewer details. However, there was an affirmation by the dispensing stuff that in the absence of patients’ forms, the student’s forms were used for patients (Conrick, 2001) It was also evident that the names of the herbs were neither written in full nor in Latin. This implied that the medical officers wrote in their local language. The proportions and types of herbs were either missing or recorded in the wrong place. For instance FE ‘fluid extract’, essential oil, infused oil. In the forms, there were five signatures that were required, but all were not signed always. This called for a discussion as to whether or not the qualified staff, that gave the prescription were be assessed by other people. The prescription form had a provision for; the practitioner who gave the prescription, the person who was responsible for making the mixture, and practitionerwho took the case were to sign. At this point, it was necessary that whenever a student was to make the prescription, it was to be checked by another member (student or staff, if applicable), in order to correct mistakes that might arose in the process. In terms of quality of information, it was found out that the information was legible and satisfactory. Much of the information was easy to understand, but there was some information that required some explanation for one to understand (Rittenberg, Johnstone, & Gramling, 2011). Use of patient’s names was also important. This was vital because it enables the practitioner to be sure that he does not administer wrong medicine. This was considered since most of the forms contained the names of the patients (Macpherson, 2007). The practitioners wre also required to inform the patients of the side effects that they were to experience after using the medicine. This was vital because it enabled the patients to take special caution. The prescription forms did not include this information, though in most cases this information was usually considered as optional. The United States of America health standards required medicines to be named appropriately. Naming medicines in terms of the condition treated and ‘Main Mix’ was against the law. In the audit, it was found out that ABC Clinic had named the medicine basing on condition and Main Mix. For instance, out of the 42 samples that were taken, 13 samples were named ‘as Main Mix’, and 14 samples names indicated purpose (e.g., for cold, stress etc.). 7 samples lacked the names, and 7 samples were named as ‘Repeat Main Mix’. As far as naming of the medicines was concerned, even though a prescription was a repeat one, it was important to indicate all the herbs instead of using the word ‘repeat’. This was vital particularly for patients who used more than one mix, and those that had been attended to by the practitioner for a longer period. For long term patients, repeat could be for any previously given mix. On some prescriptions, the report indicated the previous prescription date. This was intended to make it convenient for the practitioners to keep track records, but it could be a challenge to the patients (Rittenberg, Johnstone, & Gramling, 2011). 4. Justify Standard The audit was carried out following the required health standards as required by the United States of America. In this assignment the University Code of Practice Governing Research and University Code of Ethics were considered (Hyo?Do?, M, Oyama & Swerdlow, 1992). 5. Methodology Employed There were 2000 possible random selections but out of these, only 42 selections were made. The yellow prescription forms were for four months (Nov1, 2012 -28th March, 2013). 6. Data Analysis Data collection was done by one member of the audit group. The member went to the ABC clinic dispensary and took random pictures of the yellow prescription forms .Out of the pictures that were taken, 42 yellow prescription forms were picked and used as samples during the audit. The 42 forms were to enable the auditors to make comparisons and contrasts. This was necessary in the identification of mistakes and the form completion procedures used by the clinic. The analysis cases were fairly chosen while giving equal consideration to each. The prescriptions of most of the drugs used by the patients required additional adjustments or precautions that could be employed in relation to the dangers that the patients were exposed to. The main interest for the audit was ensuring that the patients received optimal satisfaction in every CAM treatment (herbal medicine) administered to them (Lock, 1984). 7. Discussion Having done audit on the completion of the prescription forms was evident that the clinic practitioners had failed to complete the forms as required. This was an indicator of poor treatment received by the patients. It was recommended that the stated persons were to sign the forms before giving them to the patients to ensure that the patients got appropriate medicines. The issue of naming the medicines was also addressed, since the company’s failure to give appropriate names to the medicines was a breach of the required standards. It was also necessary to provide the information on the quantity of the medicine to be taken at a particular time (Zhu, 2006). The prescription was also required to provide information of the person dispensing the drug and indicate if it was a repeat treatment. Provision of the name of the patient and the medicine batch number was to enhances proper treatment, since the medical practitioner could know and understand the needs of the clients. There was need for distinction between the patients’ forms and the students’ forms. The forms could be differentiated by producing them in different colors. This could enhance quick identification in case of a mix up (Bilello, 2005). Generally, when carrying out an audit, several limitations are incurred. During our audit, we found it hard to determine the factors that were considered in preparation of the prescriptions. The second limitation was that we were not sure of the time frame in which the clinic was to implement the suggested adjustments. This was because most of the doctors were not employed on a permanent basis, while others were students who were just doing their practice in the clinic. The practitioners were also required to consider the issue of age and weight when setting up the prescription standards in order to lower the errors that could occur during prescription. Additionally, for the purposes of enhancing awareness and educational involvement, the clinic was to incorporate; IT and strategic undertakings. This would ensure that patients were weighed before they started any treatment (Bilello, 2005). 8. Reflections on doing the Audit &Implecations for Practice In the preparation of our audit, the issue of good practice was addressed through identification of standards that govern the health sector. This was vital because it facilitated auditing procedures for the purpose of expressing our opinion on the yellow prescription forms while avoiding disclosing information on the internal control over patient information collection and storage. Our audit gives major consideration on the effectiveness of the information provided on the yellow prescription forms (Watson & Preedy, 2008). There were notable weaknesses in terms of internal data control that the clinic needs to address. The audit was carried out basing on auditing standards that are acceptable in the United States of America. It is a requirement that we organize and carry out the audit in order to come up with reasonable assurance about the reliance of the information available on the yellow prescribed forms. The audit entails the assessment of the evidence presented on the sample yellow forms collected from the clinic. An audit also includes assessing the entire CAM treatment (herbal medicine) that is administered to the patients. We suppose that our audit offers a logical basis for our judgment (Bowden, 2004). 9. Ethical Considration Data was selected at random and without considering specific conditions, but with an aim of analysis and interpretation. During the data analysis process, all the available information was accorded the necessary respect and confidentiality. In order to uphold our ethical standards we agreed that after the research assignment, the information was to be destroyed. Although we conformed to the University guidelines, it was not required for our type of audit (Zhu, 2006). 10. Precis In every organization, constant audits are always necessary. This is because they help the organization to identify their weaknesses and perfect them. In order to ensure that all organizations carry out constant and comprehensible audits, there are audit standards set for all sectors. For instance, in this paper an audit was carried out on a herbal clinic which falls under the health sector. Herbal clinics are currently authorized to carry out their activities just like the normal health clinics. Due to this reason, an audit was carried out on Completion of Yellow Prescription Form in a Clinic File for CAM treatment (herbal medicine). All the audit principles for a standard audit were considered. The title of the audit was Completion of Yellow Prescription Form in a Clinic File for CAM treatment (herbal medicine). The rationalty of the audit was to ensure that the prescription met the required standards. The theoritical background was offered where information was offered on the bad effects of poor prescriptions, thus there was need for patients to be given proper prescriptions. In the audit criteria the pictures of the prescription yellow forms from the clinic were taken, sampled and analysed. The results were recorded, analysed and the necessary recommdatiions made. Ethical issues were also addressed since information was collected without bias and the necessary respect and confidentiality was accorded to it. In the audit. In the area of reflection on doing audit and implecations for practice, there were several areas that were to be addressed. For instance the issue of the time frame that the clinic required to implement the recommendations, the issue of the relationship between quantity of medicine to be taken , age and weight of the individual.It was also necessary to establish the conditions that made the practitioners to come up with the existing prescription. References Bilello, N, 2005, ‘Understanding the difficult patient: a guide for practitioners of Oriental medicine’, Boulder, Colo, Blue Poppy. Bowden, J, 2004, ‘Writing a report: how to prepare, write and present effective reports’, Oxford, How To Books. Carson, P. A., & Dent, N. J, 2007, ‘Good clinical, laboratory and manufacturing practices: techniques for the QA professional’, Cambridge, RSC Publ. Cascarino, R, & Van esch, S, 2007, ‘Internal auditing: an integrated approach’, Lansdowne, South Africa, Juta. Conrick, J 2001,’Neem, the ultimate herb’, Twin Lakes, WI, Lotus Press. Dauber, N. A, 2009, ‘The complete guide to auditing standards, and other professional standards for accountants, 2009’, Somerset, N.J., Wiley. Hyo?Do?, M, Oyama, T, & Swerdlow, M, 1992, ‘The pain clinic IV: proceedings of the fourth international symposium, Kyoto, Japan, 18-21 November 1990’, Utrecht, The Netherlands, VSP. Lock, M. M, 1984, ‘East Asian medicine in urban Japan: varieties of medical experience, Berkeley’, University of California Press. Macpherson, H, 2007, ‘Acupuncture research: strategies for establishing an evidence base’, Edinburgh, Churchill Livingstone Elsevier. Rittenberg, L. E, Johnstone, K. M, & Gramling, A. A,2011, ‘Auditing’ Mason, Ohio, South-Western. Stamp, E, & Moonitz, M, 1979, ‘International auditing standards’, Englewood Cliffs, N.J., Prentice-Hall International. Watson, R. R, & Preedy, V. R, 2008, ‘Botanical medicine in clinical practice’, Wallingford, UK, CABI. Zhu, H. Z, 2006, ‘Running a safe and successful acupuncture clinic’, Edinburgh, Elsevier. Read More