门诊癌痛和慢性疼痛患者信息化管理平台的建立与实践  

Establishment and Practice of Information Management Platform for Cancer Pain and Chronic Pain Patients in Outpatient Department

作　　者：龚晓英[1] 马晶晶[1] 虞勋[1] 程姣[1] 郑晓娴[1] 

机构地区：[1]苏州大学附属第一医院药学部,江苏苏州215006

出　　处：《中国药房》2018年第4期450-454,共5页China Pharmacy

基　　金：苏州市科技发展计划项目(No.SYSD2017152)

摘　　要：目的:实现门诊癌痛和慢性疼痛患者的规范化管理与随访。方法:设计并建立门诊癌痛和慢性疼痛患者信息化管理平台,包括信息录入、信息查询、提前配药提示、档案统一管理、定期筛选去除多余病历等版块,介绍该平台使用时首诊、复诊、随访患者开具麻精药品的流程。比较平台建立前后档案管理情况和处方合理性,统计平台建立后药师建议采纳情况。结果:信息化管理平台建立后,患者档案的完善情况和处方的合理性有了明显改善。与平台建立前比较,问题档案的比例从42.96%降至7.06%(P<0.05);不合理处方的比例从4.39%降至1.19%(P<0.05)。药师针对疼痛控制较差的患者和存在不良反应的患者共提出建议1 542条,建议采纳率为63.62%。结论:该平台的建立有效完善了门诊癌痛和慢性疼痛患者的档案管理,提高了处方的合理性,同时也发挥了药师在门诊疼痛治疗中的作用。OBJECTIVE:To complete standardized management and follow-up for the cancer pain and chronic pain patients in outpatient department. METHODS:Information management platform was designed and established for cancer pain and chronic pain patients in outpatient department,including information entry,information inquiry,prompt for drug dispensing in advance,file unified management and regular scanning and removing excess medical records. The procedure of prescribing narcotic drugs for first visiting,subsequent visiting and follow-up patients was introduced. File management and prescription rationality before and after the establishment of information platform were compared. The adoption of pharmacist's recommendation after the establishment of information platform were counted. RESULTS:Compared with before the establishment of information platform,the ratio of problematic profiles decreased from 42.96% to 7.06%(P<0.05);the ratio of irrational prescription decreased from 4.39% to 1.19%(P<0.05). Pharmacists provided a total of 1 542 recommendations for the patients with poor pain control and ADR. The adoption rate of the pharmaceutical recommendations was 63.62%. CONCLUSIONS:The cancer pain and chronic pain information management platform can manage the outpatients' profile effectively and improve the rationality of the prescription. Meanwhile,the pharmacists have played an important role in the pain treatment for outpatients.

关 键 词：疼痛 门诊患者 麻精药品 药学服务 信息化 

分 类 号：R95[医药卫生—药学]