基于医院信息系统的中药饮片处方抽样点评结果及模式分析研究  

Results and Pattern Analysis on Sampling Prescription Review of Chinese Herbal Medicine Based on Hospital Information System

作　　者：国琦 郭桂明[1] 李璐瑒[1] 车晓平[1] 范峥[1] 刘洋[1] GUO Qi;GUO Guiming;LI Luyang;CHE Xiaoping;FAN Zheng;LIU Yang(Dept.of Clinical Pharmacy,Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University,Beijing 100010)

机构地区：[1]首都医科大学附属北京中医医院临床药学科

出　　处：《中国医院用药评价与分析》2020年第1期110-113,117,共5页Evaluation and Analysis of Drug-use in Hospitals of China

基　　金：国家中医药管理局临床中药学重点学科项目(No.国中医药人教教育便函〔2012〕170号)

摘　　要：目的:探讨中药饮片处方点评系统的优势与不足,为优化点评机制提供信息化手段,从而提高合理用药水平。方法:回顾性分析2018年首都医科大学附属北京中医医院中药饮片处方点评统计资料,对医院信息系统中药饮片处方点评模式进行讨论和结果汇总。结果:共抽取11 757张处方进行点评,其中不合理处方192张,处方不合理率为1. 6%;手工筛除因系统上看不到毒性药超量、"十八反、十九畏"药是否双签字而判定成为不合理的处方,剩余115张不合理处方。115张不合理中药饮片处方主要涉及9类问题,处方数排序居前3位的问题是诊断、证型与用药选择不符(51张,占44. 3%),无特殊情况需要适当延长处方用量未注明理由(30张,占26. 1%)和用法与用量不适宜(11张,占9. 6%)。结论:应用医院信息系统进行中药饮片处方点评,能保证抽样的合理性,并且提高了工作效率和水平。但是与纸质处方相比,部分处方信息无法在电子处方中体现,点评内容有缺失,系统中饮片处方信息有待完善。OBJECTIVE: To probe into the advantage and disadvantage of prescription review system of Chinese herbal medicine,to provide information-based method for optimizing review mechanism,so as to improve rational drug application. METHODS: Data of prescription review of Chinese herbal medicine in Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University in 2018 were retrospectively analyzed to discuss and summarize the results of prescription review model of Chinese herbal medicine in Hospital Information System.RESULTS: A total of 11 757 prescriptions were extracted for review,of which 192 were irrational prescriptions,with the irrational rate was 1. 6%;manual screening was conducted on irrational prescription with excessive amounts of toxic drugs and no double signature in "eighteen incompatibilities, nineteen counteraction " drugs, 115 irrational prescriptions were remained. The 115 irrational prescriptions of Chinese herbal medicine mainly involved 9 types of problems,the top 3 problems ranked by the number of prescriptions were inconsistency in diagnosis,syndrome type and drug selection( 51 prescriptions,44. 3%),no special case to properly extend the prescription dosage without clear reasons( 30 prescriptions,26. 1%),improper usage and dosage( 11 prescriptions,9. 6%). CONCLUSIONS: The application of Hospital Information System to conduct prescription review of Chinese herbal medicine can ensure the rationality of sampling, improve work efficiency and level. However, compared with paper prescription, some information cannot be reflected in electronic prescription,with review content missing,so that the prescription information in the system needs to be improved.

关 键 词：饮片处方点评 系统点评 系统抽样 

分 类 号：R932[医药卫生—生药学]