住院药历书写模式探讨

Writing Model of Inpatient Medication Records

目的:探讨一种实用、方便的住院药历模式,促进合理用药。方法:在SOAP模式基础上,结合临床病历及通过药师问询方式采集临床资料,将医药相关信息有机结合,建立住院药历。结果与结论:建立了适合临床药学服务工作需要的住院药历;本药历模式记录患者临床病程和药物治疗过程,内容详细、记录简便,能更方便地评价药物治疗的安全性、有效性及合理性。

OBJECTIVE： To discuss an useful and convenient medication record writing mode to promote rational drug use. METHODS： Based on SOAP model, inpatient medication histories were established by combining medication data with clinical data collected from patients＇ clinical histories and pharmacists. RESULTS ＆ CONCLUSIONS. The inpatient medication records that suited to the needs of clinical pharmaceutical care have been established and in which the clinical course of diseases and drug treatment course are recorded simply yet in detail, which can facilitate the evaluation on the safety, validity and rationality of medication.