Elmutaz Eltayeb AHMED Student ID: UM11600SPH18677 Master of Public Health
An essay on:
Rational use of Medicines Practical work paper on assessment of rational use of medicines in 5 health facilities run by GOAL (INGO) in Kutum locality _North Darfur Sudan
ATLANTIC INTERNATIONAL UNIVERSITY HONOLULU, HAWAII th 2011 June 12
1
Table
of contents: Page
TOPIC
Summary Resources and methods Questionnaire and interview Indictors of rational use of medicine Analysis Results Discussion Conclusion Recommendation Annex References
3 4 5 5 6 6 17 18 18 20 26
Abbreviations:
EDL INGO (R/P) RUD RUD WHO
Essential drug list Inte Inter r national national non-g non-gover over nmental nmental organization rganization Ret Retr r ospective ospective /pr ospective ospective r ational ational use of drug of drugs s Wo W or ld Health Health Organization Organization
2
Assessment of Rational Use of Medicines in GOAL clinics in Kutum locality North Darfur Apr 2011:
Done by: 1. Elmutaz Ahmed, Drug Management officer WHO, 2.Ismail Jukul _WHO¶s Warehouse manager-North Darfur. I. Objectives: To
evaluate the pr escr iptions and patient car e indicator s of five health facilities (Furung,Kassab,Fata bar no,Kutum center and Algarbya) run by GOAL in Kutum locality, for coher ent pr escr ibing and dispensing of drugs and to assess the patient¶s under standing r eferr ing to use of medicines, using WHO¶s indicator s. Methods: A multi-sectional, gr aphic study was carr ied out at the GOAL¶s Clinic in Kutum locality in Nor th Dar f ur state, dur ing the time per iod f r om Apr 11th -22nd. II.
Results: thor oughly 590 pr escr iptions wer e at r andom selected for study, wher ein 1141 drugs wer e pr escr ibed. Only 42% of drugs wer e pr escr ibed with their gener ic name, 100% of drugs wer e f r om the Essential drug list of Sudan. Antibiotics pr oducts wer e most commonly pr escr ibed (59% of pr escr iption wer e with Antibiotics). It was found out that assistant phar macist labeled only 90% of the medication packet with the name of the drugs, drug str ength and length of tr eatment. Only 88% of the patient knew both the length of the tr eatment and administr ation time of drugs. The pr escr iptions have shown only 3% of Injectable. III.
IV. Conclusion:
Drug use is the final step of the medical consultation. Health pr ovider s have accountability to guar antee that the corr ect drug is pr escr ibed, dispensed and taken. In br ief , ther e is need for minimum effor ts f r om GOAL to impr ove the r ational use of drugs in their suppor ted clinics. . V. Key words: patients car e, use of drugs, Rational, Irr ational, GOAL, Pr escr ibing, Dispensing
It is well known that har mless and efficient tr eatment with drugs is most possibly mainly when the end user s ar e well enlightened about their drug use 3
All health car e pr ovider s should be awar e about the r ational use of drugs. ³Rational drug use means patients r eceive medications appr opr iate to their clinical needs, in doses that meet their own individual r equir ements, for an adequate per iod of time and at the lowest cost to them and their community´ (WHO,1995). On the other hand, misunder standing of tr ade names, overwhelming consultations and dispensing of pr escr iber and dispenser s, cost aspect, patient appr oach, disrupted drug cycle, lack of standard tr eatment guidelines and list of drug for mulary can dir ect to irr ational use of drugs. In instance, irr ational drug use can negatively affect the quality of drug ther apy, amplified hazard of discarded effects, pr omote drug r esistance, enhance drugdrug inter action etc. Ther efor e, the five key cr iter ia for r ational drug use ar e corr ect diagnosis, appr opr iate pr escr ibing, r ight dispensing, pr oper packing and patient obedience. In summary, pr escr iber s should be well tr ained to be able to corr ectly diagnose the patients complains, while phar macist and assistant phar macist should be with good knowledge to advocate the patients about their tr eatment r egime as well as to f ull packing the drugs with r eliable infor mations. Resources and methods
Settings:
µKutum
pr inciple ar ea
4
The
assessment was conducted at the 5 GOAL clinics which wer e established in: Kassab IDPs camp in Apr il 2004 It cover s about 25, 810 IDPs. Fatabor no clinic in Apr il 2004 in Fatabor no Camp.it cover s about 4416, the total population is about 149,072 and ther e ar e five other f unctioning clinics. The ser vices pr ovided ar e OPDs, Phar macy, Repr oductive health (ANC, family planning, delivery r oom), dr essing r oom, ORS cor ner, labor atory, EPI, Health pr omotion ±GMP/OTP and Nutr ition - sometimes moves to other rur al locations). The aver age consultations per day in Mar ch 2011 have been 412 Staff wor king ther e includes 17 MAs in the OPD, 2 MA and 8 Phar macy assistants in the Phar macy, 38 midwives and 2 health visitor in the RH depar tment, 8 nur ses in the dr essing r oom, 1 lab assistant and 1 nur se in the labor atory. The leading morbidly causes ar e Acute Respir atory tr act infections (ARI and Diarr heal diseases. Patients attending the clinic phar macy with an official pr escr iption f r om the consultation office wer e r andomly r egister ed in the study.
Staff leveling: clinic Kassab Fata barno Furung Kutum center
MD 0 0
MA 5 1
A/PH 1
0 0
1 2
1 1
Nurse
CHW
1 1
8 2
1 2
2
MW 5 2 2 3
Questionnaire and interview: A cr oss-section questionnair e using WHO standard indicator of the r ational drug use wer e used, wher ein, r etr ospective pr escr iptions and patient infor mation wer e used as basis of the assessment. The pr escr iptions wer e analyzed. An exist inter view wer e also conducted with patients for their knowledge of the dur ation, dose, f r equency of drugs to be taken, and potential side effects of the dispensed drugs. Indictors
of rational use of drugs:
1 Prescribing indicators 1.1 Aver age number of drugs consultation 1.2 Drugs pr escr ibed by gener ic name (%) 1.3 Consultation r esulting in an antibiotic pr escr iption (%) 1.4 Consultation r esulting in an injection pr escr iption (%) 1.5 Drugs pr escr ibed f r om Essential Drugs List (%) 5
2 Patient
care indicators 2.1 Aver age consulting time 2.2 Aver age dispensing time 2.3 Drugs actually dispensed (%) 2.4 Drugs adequately labeled (%) 2.5 Patient¶s knowledge of corr ect dosage 3 Health facility indicators 3.1 Availability of Essential Drugs List/For mulary 3.2 Availability of key drugs
Analysis: Pr escr iptions wer e r andomly selected and analyzed for five indicator s (aver age drugs, pr esence of antibiotic, incidence of Injectable, gener ic names of the drugs, and drugs f r om the national list of essential medicine of Sudan), while dispensed drugs wer e checked for their accur acy of labeling, including name of drug, dur ation of tr eatment, f r equency of drug taking, name of the patient, age, and r oute of administr ation. Patients wer e assessed for consultations and dispensing time, and patients wer e checked for their r elevant knowledge of the pr oper use of their medications. Results: The
r esults wer e classified according to the WHO thr ee gr oups of indicator s:
Pr escr ibing indicator s
Patient car e indicator s
Health facility indicator s
6
1.
PRESCRIBING INDICATORS:
1.1 Average number of drugs consultation: General 450
Drugs prescribed
427
400 350 300 250
194
200
161
183
176
Fatabarno
Kassab
150
no. of drugs in all prescriptions Total
100 50 0 Furnug
F igure
Algarbeea
Kutum Center
1: General drugs prescribed in 5 supported H Fs by GOAL in Kutum locality
Total
no. of prescriptions
250 200
195
150 102 100
92
101
100
Kutum Center
Fatabarno
Kassab
50 0 Furnug
Algarbeea Total
F igure
no. of prescriptions
2: Total number of prescriptions in 5 supported H Fs by GOAL in Kutum
7
4
GOAL
supported HFs in Kutum Loc:Average no . of drugs per prescription (standard 2-3 drugs/pres)
2
1 Furnug F igure
Algarbeea
Kutum Center
Fatabarno
Kassab
3: Average drugs prescribed in 5 supported H Fs by GOAL in Kutum
For gener al drugs¶ pr escr iption, a total of 590 pr escr iptions wer e r andomly analyzed, wher e in 1141 drugs wer e pr escr ibed, with (two drugs/pr escr iption) as aver age for the assessed clinics. This aver age is good when we compar e it to the standards of Inter national Rational Use of Drugs (INRUD) (2-3 drugs/pr escr iption).
1.2 Drugs prescribed by generic name (%):
Drugs written with Generic Names 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
83%
34%
Furnug
27%
Algarbeea
Kutum Center
34%
Fatabarno
37%
Kassab
% of drugs written with Generic Names F igure1:Drugs
written with Generic Names in 5 supported H Fs by GOAL in Kutum April2011
8
Fr om the total pr escr ibed drugs (1141), ther e was only 348 drugs wer e pr escr ibed with their gener ic name, which r epr esented (30%), and according to the WHO and INRUD; all drugs should pr escr ibed by their gener ic names(100%). Her e the per for mance of mentioned clinics was var ied f r om, Algarbeea (83%) to Kutum center (27%), the r esults which r equir es a huge effor ts to suppor t with pr escr ibing by gener ic name especially in Fur nug, Kutum center,Fata bar no, and Kassab.the below example f r om differ ent countr ies
F igure4.Public
Sector Drug Use Indicator Studies 1990-1993
1.3 Consultation resulting in an antibiotic prescription (%):
% of Prescriptions with Anti-biotic
54% 76%
Furnug Algarbeea Kutum Center
47%
Fatabarno Kassab 62% 39%
F igure5:
percentage of Antibiotics in 5 H Fs (supported by GOAL)Kutum locality
9
Overuse of antibiotics, found to be the major ar ea of irr ational use of medicine in all mentioned clinics, wher ein, f ro m 590 total analyzed pr escr iptions, 348 (59%), wer e pr escr ibed with Antibiotics, in fact, this is r elatively high per centage compar ed to the WHO/(INRUD) standard (25%),this is clear ly can be seen in Fur nug clinic (76%),followed by Algarbeea, (62%) , Kassab (54%)ther efor e, WHO/GOAL needs to focus on the under lying causes and r eassess the use of Antibiotics in r espect to the seasonal fluctuation to get the r eal pictur e, to pr omote the r ational use of Antibiotics. and f ur ther mor e to minimize the antimicr obial r esistance
1.4 Consultation resulting in an injection prescription (%): percentage of prescriptions with Injections(standard 10%) 8%
8%
7% 6% 5% 4%
4%
3% 2%
1% 0%
0% Furnug
F igure
Algarbeea
0% Kutum Center
0% Fatabarno
Kassab
6: percentage prescriptions with injectables in 5 H Fs (supported by GOAL)Kutum locality
Rationally, the use of Injectable medicines is not r ecommended unless ther e ar e clear indications, For example, in comatose patients, in emergencies wher e swift actions ar e r equir ed, in cases when or al intake was r estr icted by gastr ic acid, ect.. Fr om figur e 6, all obser ved clinics wer e within the WHO/ (INRUD) standards (10%), f ur ther mor e, in 3 assessed clinics (Algarbeea,Kutum center and Kassab),the use of Injectable medicines was zer o, although ther e wer e an assor tments of Injectable medicines wer e kept in these clinics as par t of lifesaving medicine, but due to the limited time of this assessment ,the r epor ted usage of Injectable was zer o
10
1.5 Drugs prescribed from Essential Drugs List (%)
percentage of drugs prescriped from essential list of medicine (standard 100%) 100%
100%
100%
100%
100%
100%
80%
60% 40% 20% 0% Furnug
Algarbeea
Kutum Center
Fatabarno
Kassab
F igure
7: percentage of drugs prescribed from essential list of medicine in 5 H Fs (supported by GOAL)Kutum locality
In figur e 7, we obser ved that, the pr escr ibing f r om the essential list of medicine of the country is consider ed as the one of the major achievement of the RUD in all assessed clinics. (100%).
11
2 PATIENT CARE INDICATORS 2.1
Average consulting time Consultation time in 5 health facilities in Kutum locality 40 35 30 25 20 15 10 5 0
6.4 5.3
22
5.9
29 23
29 17
Furnug
Algarbeea
No. of Patients Observe d
F igure
6.4
7.4
Kutum Center
Fatabarno
Kassab
Average consultat ion time /min
8: average consultations time in 5 H Fs (supported by GOAL)Kutum locality(Apr 2011)
Accumulatively, the total consultations time for 120 obser ved patients was 759 minutes, with the total aver age (6.3) minutes/patient ,and according to the WHO definition, the consultation time is the time that enough for the health pr ovider to take the social and medical history ,r espond to the patients¶ complains. The
below figur es f r om differ ent studies for consultations time, shows that the aver age consultation was r ange f r om (2-7 minutes), the below example f r om
12
figure9: Public Sector Drug Use Indicator Studies 2000-2003
2.2
Average dispensing time:
Dispensing Time Total
dispensing time /min
NO. of Patients Observe d
Average dispensing time /min 80.0
68
66
62
70.0 60.0
50
47 29
29 23
22 2.3 2.3
50.0
17
2.7
40.0 30.0
2.3
2.8
20.0
10.0 0.0
Furn ug
F igure
Algarbeea
Kutum Center
Fatabarno
Kassab
10: average dispensing time in 5 H Fs (supported by GOAL)Kutum locality(Apr 2011)
Fr om the assessment, the aver age dispensing time for all clinics (2.4) minutes The below example f r om study conducted in differ ent countr ies 13
F igure
11: Public Sector Drug Use Indicator Studies 2000-2003
Usually, good dispensing pr ocess should include the following: (see annex 1) Receiving the pr escr iption, Pr epar ation for issuing, and Infor mation to the patient
2.3
Drugs actually dispensed (%):
Drugs Actually Dispensed No. of Prescribed Drugs 96%
No. of Dispensed Drugs
% of Actually Dispensed Drugs
100%
94%
90%
90%
44
73
44
35
57
46
81
47
39
57
Furnug
Algarbeea
Kutum Center
Fatabarno
Kassab
F igure
12: percentage of drugs actually dispensed in 5 H Fs (supported by GOAL)Kutum locality(Apr 2011)
14
Figur e 12 shows, a higher per centage of drugs actually dispensed in GOAL clinics, especially in Kassab health facility (100%), the issue which r eflects the good drug supply management system within GOAL, in fact, this indicates appr opr iate supply of drugs in all the clinics and such policy guar antees a minimum level of health car e to the population. in contr ast, This r esult was better than the per centages obtained among the other studies done in Nor th Dar fu r last year in 10 health facilities in IDPs setting (in Mallet and Elfashir) which showed (78%-85%). 2.4
Drugs adequately labeled (%):
Drugs adequetly labeled Total
no. of drugs acatually dispensed
Total
no. of drugs adequately labeled
% OF Drugs adequetly labeled
37
F igure
84%
98%
90%
89%
89%
66
43
31
51
44
73
44
35
57
Furnug
Algarbeea
Kutum Center
Fatabarno
Kassab
13: percent of drugs adequately labeled in 5 H Fs (supported by GOAL)Kutum locality(Apr
2011)
Adequately labeling of pr escr ibed drugs the selected Health facilities is var ied f r om 84% to 98%, as it shown in the figur e13. In fact, pr escr iption drug labeling is to give patients infor mation they need to take medications pr oper ly, including, name of the patient, date of dispensing, age, r esidence, sex, name of the drug, dur ation of the tr eatment, doses, ect..,
15
2.5 Patient¶s
knowledge of correct dosage:
Patient
Knowedge of correct doses
100% 90% 80%
86%
19
91%
86%
25
70%
88%
15
21
86%
25
Patients knowing accurate doses
60% 50%
No. of interviewed patients
40% 30% 20%
22
29
23
17
29
Furnug
Algarbeea
Kutum Center
Fatabarno
Kassab
10%
% of Patients with Knowledge
0%
F igure
14: patient knowledge of correct doses in 5 H Fs (supported by GOAL)Kutum locality(Apr
2011)
An exit inter views wer e conducted outside the selected facilities, the inter view was about the pr oper use of pr escr ibed drugs, the r esult shows, 87% of inter viewed patients f r om the five selected facilities wer e able to know how to use their pr escr ibed medication corr ectly. On aver age, this is as same as the r esults obtained f r om the similar assessment in other health facilities in Nor th Dar fu r state, which off cour se, indicate the ultimately needs for mor e educational effor ts at the both levels of pr escr iber s and dispenser s. 3 HEALTH FACILITY INDICATORS 3.1 Availability of Essential Drugs List/Formulary: Fr om the dir ect obser vation and inter view with existing staff within the selected health facilities, we obser ved that, ther e wer e no copies of national list of essential medicine, or national tr eatment guidelines in all assessed clinics, in fact, such documents will suppor t the health pr ovider s to manage cases according to the FMoH standards case management pr otocols, besides suppor ting them in pr escr ibing with gener ic names and pr oper ly label pr escr ibed drugs. 3.2 Availability of key drugs: A list of key drugs was found in all selected facilities, see annex 2.
16
Discussion: i
The
aver age number of drugs per pr escr iption was found to be mor e or less two in our assessment which is matching with WHO/(INRUD) standard; fewer number of drugs in pr escr iption is a positive indication as polyphar macy is known to be a causal factor for drug-drug inter actions, , patient conf usion over use of multi drugs, unpleasant drug r eactions. However, this is not desir able in all conditions as in some diseases like hear t failur e, the tr eatment r equir es mor e drugs.
i
Only 30% of drugs wer e pr escr ibed by gener ic name in this study. This value is less than that r epor ted in other assessments done in PHC clinics in other IDPs settings in Nor th Dar f ur (Sudan) in 2010. Pr escr ibing by gener ic name assists in r eduction of conf usion of health pr ovider s while pr escr ibing or dispensing. Mor eover, using gener ic names can help in drug inventory within the facility, and suppor t the pur chase system, and over all, it can pr omote for tr anslucently as most of drugs companies ar e pushing for using their br ands.
i
The
i
Infor mations obtained f r om assessing the patient car e indicator s have showed that a relatively adequate consultation and dispensing times (6.3 minutes and 2.4 minutes r espectively), putting in mind that the assessed facilities wer e a pr imary health settings which in gener al r eceived patients with minor complains, and all the health pr ovider s ther e wer e f r om the local community, ther efor e, it looks that ther e was no pr oblems in communication between health pr ovider and their patients, but still ther e an effor ts to be exer t to ensur e a good patients advocacy and infor mation shar ing. In the other hand, some drugs dispensed wer e poor ly labeled (92% pr oper labeling) this per centage looks good at gener al, but, dispensing is an cor e component of r ational drug use, as it is the final position of contact between the health pr ovider s and their par ents so wr itten infor mations on the drug bag gives an ideas about how the phar macist/assistant phar macist wer e involve in the cycle of r ational use of drugs. In br ief , we have to say all drugs pr escr ibe should be of adequately labeling.
per centage of drugs pr escr ibed f ro m the essential list of Sudan was found 100% which r epr esent an excellent r esult. Pr escr ibing f r om standard for mulary can tr im down the number of unr easonable combinations incoming the mar ket and ensur e quality of r egister ed drugs within a given country.
17
i
In this study, 87% of the patients knew the dir ection time and quantity of drugs to be taken and for how long. The knowledge gr owled by the patients dur ing dispensing is essential in ensur ing patient adher ence.
i
In this assessment, it has been noticed that the overuse of Antibiotics was consider ed as a major pr oblem of the r ational use of drugs in the assessed clinics, as (59%) of pr escr iption wer e with Antibiotics compar ed to WHO standards (25%) or less, which off cour se need collabor ative effor t to advice on the r ational use of it as the overuse of Antibiotics can enhance micr obial r esistance to antibiotics.
Conclusion: The
assessment r esult shows r elatively good implementation of r ational use of drugs among the most of the selected clinics, especially, in pr escr ibing f r om the national list of essential medicine of Sudan, r elatively enough consultation/dispensing time, and limited use of Injectable, ther efor e, the assessment suggests that ther e is still scope of impr ovement in pr escr ibing and dispensing in the clinics. Wr iting with gener ic names is urgently needed, the ob ject which may suppor t in incr easing the under standing at dispenser ¶s level, and lower ing the drug cost. Overuses of antibiotics, r educed patients¶ knowledge about corr ect doses, tr im down drug labeling in drug envelope, also contr ibuted to be the main ar eas of irr ational use of medicine in GOAL clinics.
Recommendations: 1. Conduct tr ainings of health car e pr ovider s in GOAL clinics to:
Look at the incr eased usage of Antibiotics, and r efer to the standard tr eatment guidelines in case management.
Per k up the labeling of drugs, and pr omote for infor mation shar ing and getting feedback f ro m the patients.
Maintain and str ength the good supply management system at GOAL clinics
To
pr omote pr escr ibing with the gener ic names
2. Super vision and Monitor ing of drug management and r ational use of drugs ar e r equir ed in all suppor ted facilities. 18
3. Suppor t all health car e pr ovider s with standard pr otocols on pr escr ibing and dispensing pr ocess. 4. Distr ibute copies of the national list of essential medicine and standard tr eatment guidelines to the PHC facilities. 5. Conduct collabor atively (WHO-MoH) Education campaign at community level to r aise community awar eness about the use of drugs as well as to minimize the push- to -prescribe behavior of the patients.
19
Annex 1: Good dispensing process:
Steps
Don e
Not don e
Receiving the prescription 1. Receive Confirm and validate patient prescription 2. Understand and interpret prescription
name
of
Check
prescription for completeness
y y
y
y y
y
y
Name
of the patient Name of the drug and the strength Time and/or frequency of administration Duration of treatment R oute by which the drug is to be administered Date and time when the order was written Signature of the person writing the prescription
Confirm
that doses are in safe range Correctly
perform any calculations of dose and issue quantity Identify any common drug-drug interactions
In case of any doubt or incompleteness, check with the prescriber Preparation for issuing Work in teams of two for dispensing in order to double-check prescription o The first collects the drugs prescribed o The second then verifies and gives them to patients with all necessary explanations 1. Write and The label should indicate the y Tablets label before following capsules o drugs are of the Name should be 20
packed
packed in a sealed plastic dispensing bag
y
2. Select stock container
y
y
y
3. Measure or count quantity from the stock container
patient o Drug name (use generic name) o S trength (usually in mg) o Dose - amount and frequency (C lear instructions for use in a familiar language) o Quantity dispensed o N ame of the health facility o Date of dispensing o C autionary label (e.g. ³Keep out of reach of children´) Symbols might be necessary to indicate amount and frequency of dosage for patients who cannot read Select by reading the label of the container and check it with the prescription Check the expiration date on the container Do not keep too many containers open at the same time
y
H ands
y
Counting
y
y
y
21
must never be in direct contact with the medicine
can be done with a clean piece of paper and spatula, tablet counter, lid of the container in use or other clean surface Use a spoon to put tablets and capsules onto the counting tray Keep the counting devices clean at all times! Immediately after
y
counting, the container should be closed again the container R echeck label for the drug name and strength
4. R ecord the distributed items in the documentatio n sheet
Information to the patient 1. Give the patient clear instructions and advice to re-enforce the right instructions on the label
y
Information that will maximize the effect of the treatment
y y
y
y
y
y
y
How often to take the drug When to take the drug (particularly in relation to food and other medicines) How long the treatment is to last (e.g. why the entire course of an antibiotic treatment must be taken) How to take the drug (e.g. with plenty of water, chewing or swallowing), How to store the drug (e.g. avoid heat, light and dampness), Do not share drugs with other persons, K eep drugs out of the reach of children
2. Additional information Every effort should be made to confirm that the patient understands the instructions! To check if a patient really understands, have them repeat what they were told
22
Annex 2:List of key drugs in No
Health
facilities
Drug items
Unit
1
Or al Rehydr ation Salt
Sachet
2
Cotr imoxazole tablets
tablets
3
Pr ocaine penicillin
Injection
4
Benzyl penicillin
Injection
5
Par acetamol tablets
tablets
6
Ferr ous salt+folic Acid
tablets
7
Mebendazole tablets
tablets
8
Tetr acycline
9
Iodine
Bottle
10
Gentian
Bottle
11
Benzoic Acid
Bottle
eye ointment
Tube
12 Acetyl salicylic tablet
tablets
13 Ar tesunate 50 mg, 100mg
tablets
23
Annex 3:
Prescribing
indicator form:
Location: ---------------------------------------------------------Investigator: -----------------------------------------------------
Se q
Type(R/P)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Total Aver age per centage
D ATE OF Age(yr) Rx
No. drugs
No
generic
% of Total drugs
24
% of Total cases
Date:------------------------ Antibi (0/1)
Inj(0/1)
% of Total cases
% of Total drugs
No on EDL
Diagno sis (option al)
Annex 4: Patient care form: Location:-----------------------------------------------------------------------Investigator:------------------------------------------------------------Date :------------------Se q
Patient Consultati identifier (if on time needed) (mins)
Dispensing Number of Number No Knows time (secs) drugs of drugs adequate dosage pr escr ibed dispensed labelled (0/1)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 count Total Aver age per centage
0=No
1=yes 25
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