在我国建立标准化药历的初步探索

Establishment of Standard Medication History in China

目的:探索在我国建立标准化药历。方法:参考国外药历模型,同时考虑患者、医师、临床药师3方面因素,紧紧围绕药学服务的工作重心来尝试构建我国的标准化药历,并结合一个糖尿病病例进行说明。结果:结合表格和文字,初步建立起以首页、记录表、进程和小结4部分组成的药历。结论:所建药历简明、全面、易懂,凸显临床药师的工作特点,在一定程度上能适应目前临床药学工作的需要。

OBJECTIVE： To explore the way to establish standard medication history in China. METHODS： To establish Chinese standard medication history by referring to other medication history pattern abroad, considering three factors - patients, physicians and pharmacists centered on the pharmaceutical care, and taking a case of diabetes mellitus patient as example to explain it clearly. RESULTS： The medication history was established by combining tables and descriptions, which consisted of four parts： First page, Record chart, Procedure and Summary. CONCLUSION： This medication history is concise, comprehensive, and legible, and it highlights the characteristics of pharmacists＇ job and meets the needs of clinical pharmacy practice.