住院病历抗菌药物医嘱点评效果及价值研究  

Study on the Effect and Value of Medical Advice Comment on Antibiotics in Hospital Records

作　　者：高飞[1] 胡庭杰[1] GAO Fei;HU Tingjie(Central Hospital of Sanmenxia City,Sanmenxia Henan 472000,China)

机构地区：[1]三门峡市中心医院,河南三门峡472000

出　　处：《药品评价》2021年第16期1013-1015,共3页Drug Evaluation

摘　　要：目的:探讨住院病历抗菌药物医嘱点评效果及价值研究。方法:随机抽取三门峡市中心医院2020年1季度的住院病历220份,对不合理抗菌药物医嘱进行点评,将点评前后的抗菌药物使用率、联用率、使用强度进行比较。结果:220份住院病历抗菌药物医嘱进行合理点评,发现不合理的抗菌药物医嘱共120例,占比54.55%,其中无适应证用药占比最高,占比35.83%,其次为超剂量用药,占比29.17%;120例不合理抗菌药物医嘱中,外科出现不合理的医嘱占比最大,为24.17%;其次为呼吸内科,占比21.67;骨科占比16.67%;经过点评后,抗菌药物使用率及联用率分别为55.45%及40.00%,低于点评前的80.91%及62.73%;点评后,一、二代头孢抗菌药物使用强度显著高于点评前,三、四代头孢抗菌药物使用强度显著低于点评前。结论:住院病历抗菌药物医嘱点评可合理修正不合理抗菌药物医嘱,对临床抗菌药物的使用提供有效指导,促进抗菌药物的合理使用,使得抗菌药物得到科学化管理。Objective:To explore the effect and value of antimicrobial doctor's order review in inpatient medical records.Methods:220 inpatient medical records of the hospital in the first quarter of 2020 were randomly selected to comment on unreasonable antimicrobial orders,and the utilization rate,combination rate and use intensity of antibiotics before and after the comment were compared.Results:220 inpatient medical records were reasonably commented on antimicrobial orders,and 120 unreasonable antimicrobial orders were found,accounting for 54.55%,of which the proportion of medication without indications was the highest,accounting for 35.83%,followed by over dose medication,accounting for 29.17%;among the 120 cases of unreasonable medical orders for antibiotics,the largest proportion of unreasonable medical orders in surgery was 24.17%;the second was respiratory medicine,accounting for 21.67;orthopedics accounted for 16.67%;after the review,the utilization rate and combination rate of antibiotics were 55.45%and 40.00%respectively,lower than 80.91%and 62.73%before the review;after the review,the use intensity of the first and second generation cephalosporins was significantly higher than that before the review,and the use intensity of the third and fourth generation cephalosporins was significantly lower than that before the review.Conclusion:The review of antimicrobial orders in inpatient medical records can reasonably correct unreasonable antimicrobial orders,provide effective guidance for the use of clinical antibiotics,promote the rational use of antibiotics,and make antibiotics managed scientifically.

关 键 词：住院病历 抗菌药物 医嘱点评 

分 类 号：R95[医药卫生—药学]