Overview of the MediDocQ contents and descriptive of individual items
| Key themes | G(eneric) and A(dditional) aspects | Appraisal criteria | Type of answer scale | N | Mean (SD) normed values* | Median (IQR) original values* |
| Completeness of information | ||||||
| Medical prescriptions on admission to the unit (regularly scheduled medications without PRN medication) | G01: Date, time and signature of medical prescription | (1) Prescription with date | Ordinal | 1243 | 0.80 (0.36) | 4.00 (3.00–4.00) |
| (2) Prescription with time | Ordinal | 1243 | 0.18 (0.35) | 1.00 (1.00–2.00) | ||
| (3) Prescription signed/initialled by physician | Ordinal | 1243 | 0.81 (0.34) | 4.00 (3.00–4.00) | ||
| G02: Completeness of medical prescriptions | (4) Prescription clearly legible | Continuous | 1243 | 0.91 (0.16) | 1.00 (0.87–1.00) | |
| (5) Prescription with dose | Continuous | 1237 | 0.81 (0.23) | 0.86 (0.69–1.00) | ||
| (6) Prescription with unit of dose | Continuous | 1238 | 0.69 (0.30) | 0.75 (0.50–1.00) | ||
| (7) Prescription with dose interval | Continuous | 1238 | 0.94 (0.14) | 1.00 (0.95–1.00) | ||
| (8) Prescription with route of administration (eg,IV/IM) | Ordinal | 1238 | 0.74 (0.39) | 3.00 (2.00–4.00) | ||
| G03: Duplicated medication prescription | (9) Duplicated medication prescription (eg, same medicine is prescribed twice with identical information without being ceased or changed in-between the two entries) (r*) | Dichotomous | 1242 | 0.92 (0.28) | 1.00 (1.00–1.00) | |
| Documentation of medication administration during hospital stay (regularly scheduled medications without PRN medication) | G04: Standards for documentation of medication administration | (10) Medications such as tablets, drops, ointments, eye drops, inhalants or enemas (p.o. rectal, topical and so on) generally initialled by physician/nurse when administered | Ordinal | 1200 | 0.45 (0.41) | 3.00 (1.00–3.00) |
| (11) S.c./IV/IM medications generally initialled by physician/nurse when administered | Ordinal | 1091 | 0.61 (0.39) | 3.00 (2.00–4.00) | ||
| (12) Medications ticked off or initialled even if not prescribed to be given at a certain time (r*) | Ordinal | 1275 | 0.99 (0.06) | 4.00 (4.00–4.00) | ||
| G05: Missing medication administration | (13) Medications such as tablets, drops, ointments, eye drops, inhalants or enemas (p.o. rectal, topical and so on) not ticked off or initialled (r*) | Continuous | 1285 | 0.86 (0.35) | 1.00 (1.00–1.00) | |
| (14) S.c./i.m./ i.v. medication in medication administration chart not initialled (r*) | Continuous | 870 | 0.57 (0.50) | 1.00 (0.00–1.00) | ||
| PRN medication |
A01: PRN medication
(rated if applicable) | (15) Medical prescription exists | Ordinal | 914 | 0.72 (0.41) | 4.00 (2.00–4.00) |
| (16) Symptoms or indications for use specified | Ordinal | 742 | 0.17 (0.35) | 1.00 (1.00–1.00) | ||
| (17) Individual and maximum daily dose specified | Ordinal | 741 | 0.66 (0.36) | 3.00 (2.00–4.00) | ||
| (18) Compliance with an individual and maximum daily dose, when the medication was applied | Ordinal | 329 | 0.93 (0.21) | 4.00 (4.00–4.00) | ||
| (19) Documentation of symptoms or indications, when medication was applied | Ordinal | 403 | 0.48 (0.43) | 3.00 (1.00–4.00) | ||
| Telephone/ verbal prescriptions |
A02: Telephone/verbal prescriptions
(rated if applicable) | (20) Telephone/verbal prescription documented in the medical prescription | Ordinal | 133 | 0.55 (0.49) | 4.00 (1.00–4.00) |
| (21) Information on telephone/verbal prescription in medication administration chart signed by a physician | Ordinal | 134 | 0.14 (0.34) | 1.00 (1.00–1.00) | ||
| Quality of transcription from prescription chart to medication administration chart | ||||||
| Transcription of medical prescription on admission to the unit (regularly scheduled medications without PRN medication) | G06: First medication administration chart (five or 7 days) | (22) Number of prescribed medications in prescription chart corresponds with the number of medications transcribed into medication administration chart | Dichotomous | 1241 | 0.59 (0.49) | 1.00 (0.00–1.00) |
| (23) Medication name transcribed correctly | Ordinal | 926 | 0.96 (0.13) | 4.00 (4.00–4.00) | ||
| (24) Medication dose transcribed correctly | Ordinal | 925 | 0.95 (0.15) | 4.00 (4.00–4.00) | ||
| (25) Medication unit of dose transcribed correctly | Ordinal | 924 | 0.96 (0.15) | 4.00 (4.00–4.00) | ||
| (26) Medication dose interval transcribed correctly | Ordinal | 917 | 0.83 (0.29) | 4.00 (3.00–4.00) | ||
| (27) Medication route of administration (eg, IV/IM) transcribed correctly | Ordinal | 900 | 0.89 (0.27) | 4.00 (4.00–4.00) | ||
|
A03: Second medication administration chart (five or 7 days) (rated if applicable) | (28) Number of prescribed medications in the first medication administration chart corresponds with the number of medications transcribed into second medications chart | Dichotomous | 605 | 0.82 (0.39) | 1.00 (1.00–1.00) | |
| (29) Medication name transcribed correctly from first to second medication administration chart | Ordinal | 595 | 0.97 (0.10) | 4.00 (4.00–4.00) | ||
| (30) Medication dose transcribed correctly from first to second medication administration chart | Ordinal | 593 | 0.98 (0.10) | 4.00 (4.00–4.00) | ||
| (31) Medications unit of dose transcribed correctly from first to second medication administration chart | Ordinal | 593 | 0.98 (0.08) | 4.00 (4.00–4.00) | ||
| (32) Medications dose interval transcribed correctly from first to second medication administration chart | Ordinal | 584 | 0.88 (0.26) | 4.00 (4.00–4.00) | ||
| G07: Transcription errors/ not prescribed medication | (33) Medication without medical prescriptions documented in medication administration chart (r*) | Continuous | 1270 | 0.46 (0.50) | 0.00 (0.00–1.00) | |
| (34) Medications prescribed, but not transcribed into medication administration chart (r*) (proportion of two variables (1) actual number of newly prescribed medication in the prescription chart and (2) actual number of transcribed orders in medications administration chart) | Continuous | 1267 | 0.97 (0.11) | 1.00 (1.00–1.00) | ||
| Adjustments in medication during hospital stay (without PRN medication) | G08: Transcription of adjustments in medication | (35) Not enough or too much-changed medication (r*) (proportion of two variables counting (1) changed medication in the prescription chart and (2) changed medications in medications administration chart) | Continuous | 1226 | 0.68 (0.42) | 1.00 (0.25–1.00) |
| G09: Timely adjustment of medication | (36) Date of adjustment in the prescription chart corresponds with the date of adjustment in medications chart | Ordinal | 620 | 0.95 (0.15) | 4.00 (4.00–4.00) | |
| Compliance with chart structure, legibility and handling of deletions and corrections | ||||||
| Chart structure and legibility (without PRN medication) | G10: Prescription chart (physicians) | (37) Documentation in prescription chart generally legible/clear | Ordinal | 1111 | 0.81 (0.21) | 3.00 (3.00–4.00) |
| (38) Compliance to prescriptions chart structure (eg, initials made where designated) | Dichotomous | 1110 | 0.81 (0.40) | 1.00 (1.00–1.00) | ||
| (39) Sufficient space given prescription chart structure (eg, no overwriting of other fields) | Dichotomous | 1111 | 0.86 (0.35) | 1.00 (1.00–1.00) | ||
| (40) Pencil documentation in prescription chart (r*) | Dichotomous | 654 | 0.95 (0.21) | 1.00 (1.00–1.00) | ||
| (41) Use of symbols, abbreviations or characters (eg, arrows) with no clear meaning (r*) | Dichotomous | 1110 | 0.93 (0.26) | 1.00 (1.00–1.00) | ||
| G11: Medication administration chart (nurses) | (42) Documentation in medication administration chart generally legible/clear | Ordinal | 1278 | 0.86 (0.18) | 4.00 (3.00–4.00) | |
| (43) Compliance to medication administration chart structure (eg, initials made were designated) | Dichotomous | 1278 | 0.86 (0.34) | 1.00 (1.00–1.00) | ||
| (44) Sufficient space provided in medication administration chart structure (eg, no overwriting of other fields) | Dichotomous | 1279 | 0.89 (0.31) | 1.00 (1.00–1.00) | ||
| (45) Pencil documentation in medication administration chart (r*) | Dichotomous | 1261 | 0.81 (0.39) | 1.00 (1.00–1.00) | ||
| (46) Use of symbols, abbreviations or characters (eg, arrows) with no clear meaning (r*) | Dichotomous | 1279 | 0.92 (0.27) | 1.00 (1.00–1.00) | ||
| Deletions/corrections |
A04: Prescription chart (physicians)
(rated if applicable) | (47) Deletions/corrections are tidy (text should still be readable) | Ordinal | 491 | 0.51 (0.41) | 3.00 (1.00–4.00) |
| (48) Deletions/corrections are initialled | Ordinal | 491 | 0.05 (0.20) | 1.00 (1.00–1.00) | ||
| (49) Deletions/corrections are dated | Ordinal | 491 | 0.02 (0.13) | 1.00 (1.00–1.00) | ||
| (50) Use of corrections fluid (r*) | Dichotomous | 494 | 1.00 (0.06) | 1.00 (1.00–1.00) | ||
|
A05: Medication administration chart (nurses)
(rated if applicable) | ( 51) Deletions/corrections are tidy (text should still be readable) | Ordinal | 644 | 0.53 (0.41) | 3.00 (1.00–4.00) | |
| (52) Deletions/corrections are initialled | Ordinal | 644 | 0.02 (0.13) | 1.00 (1.00–1.00) | ||
| (53) Deletions/corrections are dated | Ordinal | 644 | 0.01 (0.09) | 1.00 (1.00–1.00) | ||
| (54) Use of corrections fluid (r*) | Dichotomous | 645 | 0.99 (0.08) | 1.00 (1.00–1.00) | ||
*For unique descriptive description and comparison, means and SDs are presented for normed values ranging between 0=poor and 1=excellent. Median and interquartile ranges are presented on the original answer scale for individual items.
PRN, pro re nata; (r*), reverse coded items; Italic items, additional components for sub-indices.