我院门诊麻醉药品病历书写情况分析及对策  

Analysis of outpatient narcotics medical record writing situation in our hospital and its countermeasure

作　　者：陈金凤[1] 朱青梅[1] 钟明[1] 王玉博[1] 刘冰[1] 

机构地区：[1]新疆医科大学第一附属医院药学部,新疆乌鲁木齐831100

出　　处：《中国医药导报》2017年第21期181-184,共4页China Medical Herald

基　　金：新疆医科大学人文社会科学基金项目(2015XY DSK09)

摘　　要：回顾性统计2014年1月~2015年12月新疆医科大学第一附属医院(以下简称"我院")门诊药房麻醉药品病历的书写情况,分析归纳不规范麻醉药品病历的类型,采取相应的对策,通过查阅文献,参考癌症规范化药房的病历书写,并与临床沟通,设计出符合我院实际的门诊麻醉药品病历新版本,投入使用。对我院门诊临床医生及药房药师进行培训后,再次统计分析2016年6~12月新模板病历书写不规范情况。通过前后统计数据对比,采用新的政策后,不规范病历书写明显降低,提高了我院门诊麻醉药品病历的书写规范性。This article retrospectively investigates the outpatient narcotics medical record writing situation in the First Affiliated Hospital of Xinjiang Medical University From January 2014 to December 2015, analyzes the types of non-standard narcotics medical record, adopts corresponding countermeasures, through literature review, reference of cancer normalized pharmacy＇s medical history writing, and communication with clinical, designs new version of outpatient narcotics medical record in accordance with reality of our hospital, and puts into use. After train of outpatient clinical physicians and pharmacy pharmacists, this article investigates new version record non-standard writing from June to December 2016 again. Through comparsion between before and after, after adopting the new policy, non-standard medical record writing is decreased obviously, which improve the standard of outpatient narcotics medical record writing in our hospital.

关 键 词：麻醉药品病历 疼痛评分 书写规范 

分 类 号：R197.323[医药卫生—卫生事业管理]