Quality statement 3: Recording information

Quality statement

People prescribed an antimicrobial have the clinical indication, dose and duration of treatment documented in their clinical record.

Rationale

Recording in patients' records the clinical indication (that is, the results of clinical assessment, symptoms and diagnosis) for an antimicrobial, and the prescribed dose and duration of treatment, allows better management during follow-up of care and transfer of care to another setting. It also supports monitoring of prescribing practice and identification of appropriate and inappropriate prescribing in all settings.

Quality measures

Structure

Evidence of local arrangements and processes to ensure that all prescribers document the clinical indication, dose and duration of treatment in patients' records when prescribing an antimicrobial.

Data source: Local data collection.

Process

Proportion of prescriptions for antimicrobials with the clinical indication, dose and duration of treatment documented.

Numerator – the number in the denominator with the clinical indication, dose and duration of treatment documented.

Denominator – the number of prescriptions for antimicrobials.

Data source: Local data collection, Start smart then focus tools and TARGET Antibiotics toolkit.

Outcome

Antimicrobial prescribing rates.

Data source: Local data collection.

What the quality statement means for service providers, prescribers and commissioners

Service providers (such as hospitals, walk‑in centres, GP practices, health centres, dental care providers, pharmacies, community services) monitor standards of record‑keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.

Prescribers document in patients' clinical records the clinical indication, dose and duration of treatment when they prescribe antimicrobials.

Commissioners (clinical commissioning groups, NHS England) ensure that services monitor standards of record‑keeping to check that clinical indication, dose and duration of treatment are documented when antimicrobials are prescribed.

What the quality statement means for patients, people using services and carers

People who are prescribed an antimicrobial have the reason recorded in their medical record, as well as how long they should take the antimicrobial and the dose.

Source guidance