电子处方和手写处方书写规范度对比研究.docVIP

电子处方和手写处方书写规范度对比研究 　　[摘要] 目的 了解南华大学附属医院《处方管理办法》的贯彻落实情况，对比分析手写处方和电子处方书写规范度的差异，为规范处方使用提供依据。 方法 采用随机抽样调查的方式，依据处方点评标准，对南华大学附属第一医院、附属第二医院新院、附属第二医院老院处方规范率及不规范表现进行统计分析。采集电子处方和手写处方的不规范数据，分析比较不合理差异。 结果 经过抽样调查，南华大学附属第一医院的处方（全部为电子处方）不规范率最低，为12.92%；附属第二医院新院的处方（部分电子处方）不规范率较高，为22.70%；附属第二医院老院的处方（全部为手写处方）不规范率最高，为35.89%；经过多个样本比较的Friedman M检验分析，三组数据差异有统计学意义（P 0.05）。电子处方中不规范处方占13.38 %，远远低于手写处方不规范率34.29%，且差异有高度统计学意义（P 0.01）。手写处方中的不规范表现较多，集中体现为前记、规格、药名错误，药师未执行双签名规定等方面，而电子处方不规范的因素比较单一，主要是婴儿处方未写明体重或日、月龄。 结论 医院应该加强处方书写方面的管理力度，提高药剂人员的素质，强化医院的信息系统，使手写处方逐步往电子处方过渡，促进处方书写规范化。 　　[关键词] 手写处方；电子处方；书写规范 　　[中图分类号] R925 [文献标识码] C [文章编号] 1673-7210（2013）11（a）-0121-04 　　Comparative study on writing standardization degrees difference between electronic prescription and handwritten prescription 　　GUO Zifen1 ZHANG Shiyi1，2 WEI Cuiwei1 CHEN Fangfang1 XUAN Guiping1 　　1.Institute of Pharmacy and Pharmacology， University of South China， Hunan Province， Hengyang 421001， China； 2.Department of Pharmacy， the First Affiliated Hospital of University of South China， Hunan Province， Hengyang 421001， China 　　[Abstract] Objective To understand the implement situation of Prescription Management Approach in the Affiliated Hospital of University of South China and to comparatively analyze the writing non-standardization degree differences between handwritten prescription and electronic prescription， in order to provide evidence for the standardization of prescription. Methods The randomly selected prescriptions， from the First Affiliated Hospital， the New Second Affiliated Hospital and the Old Second Affiliated Hospital of University of South China， were retrospectively reviewed one by one and analyzed statistically according to the Prescription Management Approach. The prescriptions non-standard rate and standardization performance were captured for analyzing writing standardization degree difference between handwritten prescriptions and electronic prescriptions. Results The non-standard rates of prescriptions