病区医嘱点评的实践与分析.doc

我院1200份住院医嘱合理用药现状点评分析 彝良县人民医院（彝良县角奎镇黎明村22号）药剂科刘广友 657600 电话243301121@ 【摘要 】 目的：通过对我院病区医嘱用药的点评分析，为临床合理用药提供参考,有效提高了临床合理用药水平,更好了解我院住院病历的合理用药情况。方法：根据《医院处方点评管理规范（试行）》为依据，2016年8月-2016年12月年,平均每月抽查出院病历200,每个科室随机抽取20份出院病历(共1200份)，进行统计分析，主要对对不适宜遗嘱问题、辅助用药的不合理用药的具体情况分析。结果：共点评病历1200份，，不合理用药的份数有191份，合理用药率为84.08%。其中；不适宜医嘱问题主要表现为；适应症不适宜23份；药品品种选择19份；剂型或给药途径11份；用法用量135份，其他用药问题目3结论：住院病历存在很多的用药缺陷，需加强临床用药的管理，加大督查力度，促进合理用药。 【关键词 】 医嘱用药；病区；点评；病历；合理用药 Abstract Objective: through the use of drugs in our hospital ward doctor reviews analysis, provide reference for clinical rational drug use, improve the level of clinical rational use of drugs, to better understand the rational use of medical records in our hospital. Methods: according to the standard of hospital prescription review management (Trial) as the basis, August 2016 -2016 year in December, the average monthly checks of 200 cases discharged from each department, randomly selected 20 cases (1200 copies), statistical analysis, analysis of the specific situation of irrational use of drugs is not suitable for the will of the main and adjuvant drugs the. Results: a total of 1200 medical records were reviewed, and the number of irrational drug use was divided into 191 parts, and the rational drug use rate was about 84.08%. The doctor is not suitable; is the main problem; indication is not suitable for 23 copies of 19 copies; drug selection; dosage form 11; dosage 135, other drug problem orders 3 conclusions: hospital records exist many defects of drug, the need to strengthen the clinical medication management, increase supervision, promote the rational medication. Key words: doctors advice; ward; comment; medical record; rational drug use 根据《药品管理法》、《执业医师法》、《医疗机构管理条例》、《处方管理办法》病房（区）医嘱单的抽样率（按出院病历数计）不应少于1%，且每月点评出院病历绝对数不应少于30份。病房（区)用药医嘱的点评应当以患者住院病历为依据，实施综合点评，点评表格由医院根据本院实际情况自行制定【1】。”按照此规定，我院处方点评小组尝试制定表格以对病区医嘱用药的实际情况进行点评。该项工作实施以来，深切感受到病区用药医嘱点评工作的重要性，其对提高我院用药合理性、规范用药行为、保障用药安全、提高服务品质等起到了一定的促进作用。现将我院的一些具体做法介绍如下： 资料与方法