Patterns of Documenting Patients' Medical Records and Antibiotic Use for Cases with Acute Respiratory Infection in Basrah hospitals

Abstract

The present study was carried out to evaluate the process of documenting patients' medical records in addition to the pattern of antibiotic use in Basrah general hospitals. A retrospective type of study was conducted for antibiotic prescription in 562 inpatients' medical records of those who were admitted to paediatric wards in five hospitals in Basrah governorate because of acute respiratory infections. The study shows that 86% of the patients stayed for less than 5 days at the hospital with 13% of them stayed between 5-10 days. All of the 562 patients' records were reviewed for documentation of the investigations taken during hospitalization, use of antibiotics and follow up while in hospital. Around two thirds (65.5%) of the records were found to have no documentation for any investigation during hospitalization. In addition, antibiotic therapy was found to be used in 83.3% of the cases. By comparing the WHO indications for using antibiotic therapy in acute respiratory infections cases, it was found that antibiotics were prescribed without justifiable indications in 44.7% of patients. The study recommended re-enforcing the adoption of updated drugs use protocols and guidelines especially on the use of antibiotics in hospitals and specifically in inpatient pediatric age groups. Furthermore, assigning clinical pharmacists in the clinical inpatients setting is one of the study recommendations in order to monitor the clinical use of these medications.