我院医嘱点评实践中的典型案例分析  

Analysis of typical cases in practice of medical orders evaluation

作　　者：张峰[1] 朱玉萍[1] 

机构地区：[1]南通瑞慈医院药剂科,江苏省南通市226010

出　　处：《临床合理用药杂志》2015年第12期27-28,共2页Chinese Journal of Clinical Rational Drug Use

摘　　要：目的通过不合理医嘱分析规范临床用药,确保患者用药的安全和有效性。方法选取南通瑞慈医院病案室2009年7月—2012年6月归档的出院病历共1080份。每月随机抽取前1个月的出院病历30份(非手术病历和手术病历各15份),由药剂科处方点评工作小组对用药医嘱合理性进行综合点评。结果 1080份出院病历中不合理医嘱单为275份,占25.46%。结论临床药师通过医嘱点评对临床用药实施监控,可以减少和避免不合理用药的发生,促进临床安全、合理用药。Objective To standardize clinical drug utilization and ensure patient＇s medication safety and effectiveness by analysis of irrational medical orders. Methods In Nantong Rich Hospital from July 2010 to June 2012,a total of 1080 cases of medical records were selected,30 cases of medical records were randomly selected from each month,which were analyzed retrospectively by pharmacy prescription comment working group. Results Unreasonable medical advice was 275 cases（ 25. 46%） in 1080 cases of medical records. Conclusion Clinical pharmacists can promote safe,effective,economical and proper medication by medical orders evaluation.

关 键 词：处方 医嘱点评 

分 类 号：R969.3[医药卫生—药理学]