1000份住院病历点评.pdfVIP

中国药物应用与监测2011年4月第8卷第2期 Chinese Journal of Drug Application and Monitoring, Vol.8, No.2, April 2011 ·用药分析 · 1000 份住院病历点评 姚 冰，彭晓燕，李晓波（湖北省襄阳市第一人民医院药学部，湖北 襄阳 44 1000 ） [摘要] 目的：对现阶段我院住院病历医嘱合理性进行点评，为临床合理用药提供参考。方法：随机抽取我院20 10 年3 – 8 月的1000 份住院病历，根据《医院处方点评管理规范（试行）》的相关规定，对各类不合理情况进行调查分析及点评。结果： 1000 份病历中注射剂使用率100% ，使用抗菌药物的病历711份，占71.1% ；不合理病历242 份，占24.2% ，不合理频数257 次， 占25.7% 。其中，不规范医嘱频数116 次，用药不适宜医嘱频数136 次，超常医嘱频数5 次，分别占11.6% ，13.6% ，0.5% 。结 论：我院病历医嘱存在较多不合理状况，需加强临床用药合理性监测，规范处方用药。 [关键词] 住院病历；处方点评；合理用药 [ 中图分类号] R969.3　 [文献标识码] A [文章编号] 1672 – 8157(2011)02 – 0113 – 04 Reviews of 1000 medical records YAO Bing, PENG Xiao-yan, LI Xiao-bo(Department of Pharmacy, Xiangyang No. 1 Peoples Hospital, Xiangyang 441000, China) [ABSTRACT] Objective: To review the rationality of case history in our hospital, and provide the reference for rational drug use in clinic. Methods: According to relevant provisions of the management standards of hospital prescription (trial), various kinds of unreasonable cases in a random sample of 1000 medical records of our hospital from March to August in 2010 were analyzed and commented. Results: In the 1000 medical records, inj ection rate was 100%, there were 711 medical records (71.1%) which used antimicrobial agents, 242 unreasonable medical records (24.2%) and 257 unreasonable frequencies (25.7%). Among them, there were 116 non-standard medical records, 136 inappropriate medication prescriptions and 5 extraordinary medical records, accounting for 11.6%, 13.6% and 0.5% respectively. Conclusion: There are some irrational prescriptions in our hospital, the rationality of drug use should be monitored and the prescriptions should be standardized. [KEY WORDS] Medical record; Prescription review; Rational drug use 20 10 年2 月10 日卫生部下发了《医院处方点评管 范》中规定的1% 抽样率及绝对数大于30 份的要求， 理规范（试行）》（以下简称《点评规范》）的通知，以规 病历样本覆盖全院各住院科室，具有一定的代表性。 范医院