基于电子病历评价标准的合理用药系统建设与应用  

Construction and Application of Rational Drug Use System Based on Electronic Medical Record Evaluation Criteria

作　　者：王莹 张雪 赵韡 WANG Ying;ZHANG Xue;ZHAO Wei(Fuwai Hospital Chinese Academy of Medical Sciences,Beijing 100037,China)

机构地区：[1]中国医学科学院阜外医院,北京市100037

出　　处：《中国卫生信息管理杂志》2024年第6期863-868,共6页Chinese Journal of Health Informatics and Management

摘　　要：目的借助信息技术构建以电子病历(EMR)评估标准体系为基础的合理用药系统,打造智能的“通用+特色”闭环式药物应用管理体系,保障用药合理性。方法以信息化为支撑建立前置审核系统,结合患者人群特点及药品特性,设置审核知识库和综合数据分析平台,实现对用药全过程的动态监测。结果合理用药系统实现了全方位用药合理性审查,动态监测全院用药情况,对异常数据实时预警。结论合理用药系统建设能够提高医务人员合理用药意识,保障患者安全、有效、精准用药,显著降低用药风险,提高医疗服务的质量。Objective A rational drug use system based on the electronic medical record evaluation standard system is constructed with the aid of information technology,and an intelligent"general+characteristic"closed-loop drug application management system is created to ensure the rationality of drug use.Methods Supported by informatization,a pre-audit system is established.Combined with the characteristics of patient populations and drug properties,an audit knowledge base and a comprehensive data analysis platform are set up to achieve dynamic monitoring of the entire drug use process.Results The system has achieved comprehensive review of the rationality of drug use,dynamically monitored the drug use situation in the whole hospital,and provided real-time warnings for abnormal data.Conclusion The construction of a rational drug use system can enhance the awareness of rational drug use among medical staff,ensure the safe,effective,and precise use of drugs for patients,significantly reducing the risk of drug use and improving the quality of medical services.

关 键 词：知识库 前置审核 合理用药 处方质量 智能化 

分 类 号：R-058[医药卫生] R197.3