Appraisal of prescription writing skills of preclinical undergraduate students in a medical institute of Nepal

Abstract

The aim of this study was to appraise the prescription writing skills of preclinical undergraduate students
of College of Medical Sciences, Bharatpur. This prospective study was conducted over each of 150 of 1st
year and 2nd year medical students in the months of May and June 2010 under the guidelines of World
Health Organization (WHO). Prescriber’s identity, patient’s identity, the diagnosis, the symbol-Rx and
prescriber’s signature were available on 90% and above of the prescriptions written by both year students.
A large number of them also mentioned the prescriber’s address and the date of prescription. The
information, instructions, warnings and patient’s address were the most deficient aspects among prescriber’s
related components and the strength, the quantity to be dispensed and the direction for the use of drugs
were the deficient aspects of drug related components. Comparatively more deficiencies were noted for
drug related components. As an overall, the performance of 2nd year medical students was better than that
of the 1st year. This study reveals that the prescription writing skills of preclinical medical students were
sub-optimal and need emphasis for some elements during their clinical years and internship. However,
there is a good scope of learning this skill also in the existing method of pharmacology teaching.

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Introduction
The prescription is the most common clinical
intervention offered to the patients. Almost all
interaction between a doctor and a patient ends with
writing of a prescription. The prescription writing
is a clinical skill that determines largely the
outcome of a therapeutic decision. The suboptimal
prescription writing skill can lead not only to
therapeutic failure but also to wastage of our
resources, adverse clinical consequences and
economical harm to both patients and the
Original Article
Journal of College of Medical Sciences-Nepal,2010,Vol-6,No-4, 7-13
Appraisal of prescription writing skills of preclinical undergraduate students in a
medical institute of Nepal
community. The ability to prescribe commonly used
drugs safely and effectively is a core competency
expected from all medical graduates.1 They learn
this skill under the discipline of pharmacology. This
discipline is taught in most of the Kathmandu
University (KU) affiliated medical colleges in an
integrated manner with other basic medical science
subjects during the first two years of the
undergraduate medical course following the
traditional teaching methods. However, the revised
curriculum of KU gives much emphasis on the
training of medical students for rational prescribing
using the World Health Organization (WHO)
Correspondence: J. Kumar
E.Mail: drjktkhag2003@yahoo.co.in
J. Kumar1, M. M. Shaik2, M. C. Kathi3, M. S. Chetty4, A. Deka5
1Associate Professor, 2Assistant Professor, 3Lecturer, 4Professor, 5Prof. and Head, Department of Pharmacology, College of
Medical Sciences, Bharatpur, Nepal
Abstract
The aim of this study was to appraise the prescription writing skills of preclinical undergraduate students
of College of Medical Sciences, Bharatpur. This prospective study was conducted over each of 150 of 1st
year and 2nd year medical students in the months of May and June 2010 under the guidelines of World
Health Organization (WHO). Prescriber’s identity, patient’s identity, the diagnosis, the symbol-Rx and
prescriber’s signature were available on 90% and above of the prescriptions written by both year students.
A large number of them also mentioned the prescriber’s address and the date of prescription. The
information, instructions, warnings and patient’s address were the most deficient aspects among prescriber’s
related components and the strength, the quantity to be dispensed and the direction for the use of drugs
were the deficient aspects of drug related components. Comparatively more deficiencies were noted for
drug related components. As an overall, the performance of 2nd year medical students was better than that
of the 1st year. This study reveals that the prescription writing skills of preclinical medical students were
sub-optimal and need emphasis for some elements during their clinical years and internship. However,
there is a good scope of learning this skill also in the existing method of pharmacology teaching.
Key words: Prescription writing, medical students, pharmacology teaching.
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guidelines to good prescribing as the reference
standard.2, 3The College of Medical Sciences
(COMS) Bharatpur is affiliated to KU. Therefore
students of this medical college are taught about
the standard pharmacotherapeutic approach to
common clinical disorders including the procedures
of P- drug selection and Essential drugs concept.
There is a growing concern that the traditional
undergraduate teaching in pharmacology does not
train the medical students adequately for
therapeutics.4, 5, 6 The prescription writing skills of
medical students have been reported to be
suboptimal even in the settings of problem based
pharmacology teaching.7 The prescription writing
skill of preclinical medical students was reported
suboptimal also in a recent study conducted in the
eastern Nepal.8 A regular assessment of medical
students on their prescription writing skills during
their training has been suggested as a means of
minimizing the related errors and enhancing
rational prescribing in their future endeavors.9
There is no any published data on this skill of
preclinical undergraduate students of COMS
Bharatpur. Therefore the present study was planned
and undertaken with an objective to assess the
prescription writing skills of preclinical
undergraduate medical students of this medical
institute of Nepal. This study has been attempted
also with an intention to assess the effectiveness
of the existing method of pharmacology teaching
in context of rational therapeutics so as to suggest
any addition or a change in them.
Material and methods
This prospective study was carried out in the
department of pharmacology on preclinical medical
students of COMS Bharatpur in the months of May
and June 2010 during their pre-university
examination. 150 students of 1st year and 150
students of 2nd year MBBS course constituted the
whole study population. The prescription writing
skills of these students were assessed along with
other aspects of their practical examination as a
part of summative assessment through a
pharmacotherapy objectively structured practical
examination (OSPE) following the guidelines
recommended by WHO.10 A number of OSPE
stations were made to maintain the objectivity in
the questions as well as to maintain the uniformity
in the making of responses by students. The
questions for OSPE stations were framed keeping
in mind the objectives of the concerned exercises
and specific answer checklists were made for all
the questions after a detailed discussion with faculty
members of the department. Among all the OSPE
stations, at least one station included the
prescription writing exercise for a common clinical
condition. Students of both years were priorly
explained the nature of this study. They were given
a common clinical condition by lottery method to
write a prescription. Students of different years were
given different sets of common conditions
depending on the part of pharmacotherapy covered
in their respective year of teaching. They were
assessed thereafter for their performance using
preformed checklists for both the two important
divisions of a prescription i.e. the physician related
components and the drug related components. The
physician related components were comprised of
prescriber’s identity, professional degree and
registration no., prescriber’s address, date of
prescription, patient’s identity, patient’s address, the
symbol Rx, diagnosis, information, instructions and
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warnings to patient, and prescriber’s signature. The
drug related components were appropriateness of
drug(s) selected, strength of drug(s), dosage forms,
direction for use of drugs and quantity to be
dispensed. Subsequently, the score lists for
different elements of two components of written
prescriptions by two individual year students were
prepared. The mean score rates for different
components of prescriptions written by different
years of students were also calculated. The
anonymity of identity of all the respondent students
was maintained in this study. The number and the
percentage were used to express the observed data.
The data obtained were statistically analyzed using
chi-square test. P-values < 0.05 and < 0.01 were
considered statistically significant and highly
significant respectively.
Results
A total of 300 prescriptions written by the same
number of preclinical medical students were
analyzed to evaluate their skill in the concerned
area. The performance score for the physician
related components of first year students ranged
from lowest 61.33% to highest 98%, whereas that
of second year students ranged from lowest 84.66%
to highest 100% for various elements. The
percentage of prescriptions containing the
prescriber’s identity, patient’s identity, diagnosis,
the symbol Rx and the prescriber’s signature was
90% and above in both years students. The
performance score for the prescriber’s address was
97.33% i.e. above 90% among second year
students, whereas that was 89.33% i.e. below 90%
among first year students. Among the first year
students, the most deficient part of physician related
components were the information and the
instructions followed by the patient’s address as
these were written only by 61.33% and 64.66% of
the students respectively. Surprisingly these two
elements also constituted the most deficient aspect
of physician related components among the second
year students. However, the second year students
performed better than the first year students in this
respect, as these two elements were written properly
by 87.33% and 84.66% of them respectively.
Moreover the differences observed in the
performance for these elements in between first and
second year students were found to be statistically
highly significant and significant respectively. The
next deficient element among physician related
components of first year students was professional
degree and registration number as it was marked
only by 67.33% of them. However, this particular
element of prescription was written by a
comparatively better number of second year
students i.e. 90% and the difference in the number
of respondents observed in between two different
years of students was found to be once again
statistically significant.
Among the drug’s related components, the
performance score ranged from lowest 44.66% to
highest 85.33% among the first year students and
the lowest 67.33% to highest 88.66% among the
second year students. The drug(s) selected for the
given condition were found to be appropriate on
85.33% and 88.66% of prescriptions written by the
first year and second year students respectively.
Both year students performed comparatively better
for this element among the drug related
components. The most deficient aspects of this
component were found to be the strength of drug(s),
the direction for use and quantity to be dispensed
in both years of students. However, the second year
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students performed better than the first year students for these elements and the observed differences for
strength and quantity to be dispensed are statistically significant and that for direction for use is highly
significant. Further details of performance of both year students in their prescription writing skill have
been produced in Table-1.
Table 1: Performance in prescription writing skill of first and second year medical students
1. Prescriber’s identity147 98.00148 98.66
2.Professional Degree and registration no. 101 67.33135 90.00*
3. Prescriber’s address134 89.33146 97.33
4. Date of prescription130 86.66134 89.33
5. Patient’s identity146 97.33147 98.00
6. Patient’s address97 64.66127 84.66*
7. Diagnosis147 98.00150 100.00
8. Symbol-Rx135 90.00144 96.00
9. Prescriber’s signature137 91.33142 94.66
10. Information, instructions and warnings
to patient9261.33131 87.33**
Drug related components
1. Appropriateness of drug selected128 85.33133 88.66
2. Strength of drug77 51.33107 71.33*
3. Dosage form105 70.0011878.66
4. Quantity to be dispensed 7046.66 101 67.33*
5.Direction for use67 44.66 10167.33**
*P< 0.05 **P<0.01
S.
No.
ComponentsMedical Students
First Year (n = 150)Second Year (n = 150)
Number Percentage NumberPercentage
Prescriber related components
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The mean scores observed for the physician related
components and drug related components of the
first year students were 84.4% and 59.6%
respectively and that for second year students were
found to be comparatively better i.e. 93.6% and
74.6% respectively. It is evident from the result that
both year students scored less in the drug related
components of their prescriptions in comparison
to their physician related components (Table-2).
The results also suggest that the overall
performance of second year students was better than
the first year students for all the elements of both
the physician related and the drug related
components.
Table 2: Comparison of mean scores of different components of prescription between two different
years of medical students
Scoring rate
Category No. of Physician relatedDrug related
students components (%)components (%)
First year medical students 15084.459.6
Second year medical students150 93.674.6
Discussion
An ideal prescription paper should include all its
important elements to ensure a well communication
in between a prescriber and a pharmacist. The
omission of any of the needed information on a
prescription paper
miscommunication and medication errors.3
could result in
The performance scores of students of both
year for majority of elements of both the prescriber
related components and the drug related
components were observed to be only below
hundred percent in our study. This observation
suggests that the acquisition of prescription writing
skill among preclinical students of our institute is
deficient at least to some extent. This observation
is in accordance with that observed in the study of
eastern Nepal.8 Al Khaja et al from Bahrain also
reported the limited acquisition of prescription
writing skill of medical students during their pre-
clerkship period.7 In a Nigerian study, final year
medical students were found to be also deficient in
their prescription writing skills.9 However,
important elements of a prescription like the
prescriber’s and patient’s identity, the diagnosis,
the symbol-Rx and the prescriber’s signature were
available on the prescriptions of majority (>90%)
of both year students in our study. The prescriber’s
address and the date of prescription were also
available on the prescriptions of a large percentage
(>85%) of both year students in our study. The
prescriber’s identity and address on the prescription
are essential to ensure a timely approach by the
pharmacist to the physician for a clarification in
case of any confusion.11 Patient’s identity and
address are equally important to ensure that the
correct medication goes to the correct patient and
also for the purpose of identification and record-
keeping.12 Presence of these elements also provides
an opportunity to the pharmacist to contact the
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concerned patient timely in case of occurrence of
any prescribing or dispensing error.9 The date of
prescription is an important part of the patient’s
medical record that also assists the pharmacist to
recognize the potential problems including non-
compliance.12 Majority (>85%) of both year
students were also able to choose the right drug for
the given condition. This proves their
understanding of pharmacotherapeutic approach for
the common clinical conditions. Taking into
account all of these favorable findings of our study,
it can be concluded that in spite of a limitation
there is a good scope for acquisition of this skill
even in the settings of traditional pharmacology
teaching particularly when combined with
emphasis on the teaching and exercising of the steps
of rational prescribing set forth by WHO.3
Among the prescriber related components, the
information, instructions and warnings and
patient’s address were the deficient aspects in both
years. However, the performance of second year
students was significantly better for these elements.
The relevant information, instructions and warnings
are needed not only to ensure compliance and
subsequent success of given therapy but also to
prevent any adverse event related to therapy. These
elements need to be emphasized in the forthcoming
teaching sessions.
The drug related components of prescriptions
of both year students were observed to be deficient
regarding strength, dosage forms, quantity to be
dispensed and direction for use of drugs. The
inadequate attention paid for these arenas by the
students might be the reason for such deficiencies.
Therefore these arenas need to be focused and
emphasized well by the concerned teaching
faculties in the future to prevent such shortcomings.
A continuous effort to improve these parts by
students in their coming academic years can also
help to overcome these deficiencies. This is better
explained by the observation that the second year
students performed significantly better than the first
year students in our study for the strength, quantity
to be dispensed and direction for use of drugs. The
overall performance of both year students for the
drug related components in our study were more
deficient in comparison to the prescriber related
components. This observation is in conformity with
that observed in the study of Bahrain.7 It can be
concluded from these observations that the drug
related components of a prescription are
comparatively a difficult part and need special
attention of teachers as well as students.
This study also demonstrates that the overall
performance of second year students is better than
the first year. This is suggested by our finding that
the mean scores of second year students for the
physician related components and drug related
components were 93.6% and 74.6% respectively,
whereas that of first year students were only 84.4%
and 59.6% respectively. Comparatively, more
prolonged opportunity and exposure, almost evenly
spread over two years to build up the prescription
writing skill seems to be the underlying reason
behind the better performance of second year
medical students. The better performance of second
year students in comparison to first year students
also suggests that the learning of prescription
writing skill is a gradual process that builds up by
the practice over years. Therefore this requires an
extended effort and exposure even in their clinical
years and internship to gain the perfectness.
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Conclusion
This study reveals that the acquisition of
prescription writing skill of medical students during
their preclinical years is only suboptimal. There is
an urgent need to pay more attention during
preclinical years for most of the drug related
components and few but important elements of the
prescriber related components. Though there is a
limited but fairly good scope for learning of this
skill by the preclinical students even in the settings
of traditional teaching of pharmacology,
particularly when emphasis has been laid down on
the steps suggested by the WHO for rational
prescribing. However, more investigations are
required to confirm this conclusion. The acquisition
of expected competency in this skill also requires
an extended effort by the medical students as well
as the teachers in the clinical years and internship
period. Frequent formative assessment of students
for this skill at regular intervals is recommended
during preclinical as well as clinical years to point
out the defects and to provide feedbacks to students
so as to minimize the related errors in them.
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