摘要
目的:了解我院住院病历用药医嘱书写及合理用药状况。方法:分析2011年1月—2012年12月我院开展住院病历用药点评抽查的住院病历共762份,对病历用药医嘱书写的规范性及药物临床使用的合理性进行统计、分析。结果:抽查的762份病历中有529份存在不同程度的书写不规范、用药不合理现象。书写不规范主要包括药品名称、剂型规格及用法与用量书写不规范。不合理用药主要包括药物选择不合理、用法与用量不合理、给药途径错误、联合用药不合理、溶剂选择不合理及抗菌药物使用不规范。结论:我院住院病历存在诸多的用药合理性及用药医嘱书写规范性的缺陷,有待医疗质控管理部门和临床药师的密切配合,加大考核力度,促进临床合理用药及病历用药医嘱书写质量的提高。
OBJECTIVE：To investigate the writing of medication orders and rational use of drugs in the inpatient medical records of our hospital. METHODS： 762 medical records of 762 cases during random medication checking activity carried out in our hospital from January 2011 to December 2012 were analyzed statistically with regard to the standardization of the writing of medication orders and the rationality of clinical use of drugs. RESULTS： Of the 762 cases, non-standard writing and irrationality medicating in varying degrees were noted in 529 cases. Non-standard writing was noted in the writing of drug names, specifications of dosage forms and dosage ＆ administration. The non- rational use of drugs included irrationality in choice of drugs, dosage ＆ administration, route of administration, drug combination or choice of solvents or nonstandard use of antibiotics. CONCLUSION ： The rationality of use of drugs and writing of medication orders in the inpatient medical records had serious problems which await close cooperation between medical quality control management department and clinical pharmacists by intensifying prescription checking so as to improve both clinical rational use of drugs and the quality of writing of medication orders.
出处
《中国医院用药评价与分析》
2013年第7期660-662,共3页
Evaluation and Analysis of Drug-use in Hospitals of China
关键词
医嘱书写不规范
不合理用药
住院病历
分析
Non-standard writing of medication orders
Non-rational use of drugs
Inpatient medical record
Analysis
