从眼科住院病历探讨长期用药医嘱中存在的问题

Problems in doctor's advices for long-term medication from medical records in the department of ophthalmology

目的就某医院眼科糖尿病视网膜病变患者长期用药医嘱中存在的问题,探索一套规范病区用药医嘱的实施方法。方法采用回顾性调查方法,抽取2006年1月至2011年5月某院375份糖尿病视网膜病变患者病历中的长期医嘱,填写患者基本情况和用药医嘱书写情况调查表并进行分析。结果 375份病历的15771条长期医嘱中不合理用药医嘱539条,占用药医嘱的3.42%,其中不规范书写医嘱343条(2.17%),不适宜用药医嘱196条(1.24%)。结论该院病历中医嘱书写及用药情况基本合理,对医嘱书写及用药中出现的相关问题要高度重视,关注药物相互作用,制定安全、合理的联合用药方案。

To investigate the problems in doctor＇s advices for long-term medication from medical records in Ophthalmology Department of a certain hospital to formulate a set of standardized medication in endemic areas. We carried out a retrospective survey by selecting 375 long-term doctor＇s advices for patients with diabetic retinopathy from January 2006 to May 2011 in a certain hospital.Questionaire on the patients＇basic information and doctor＇s advices for medication were filled in and analyzed. We found 598 of the 15771（3.42%）long-term doctor＇s advices for medication unreasonable from 375 medical records,including 343 doctor＇s advices irregularly written and 196 doctor＇s advices with unsuitable medication. The writing and medication in the doctor＇s advices in this hospital is basically reasonable.We should attach great importance to the writing and medicine in the doctor＇s advice,pay attention to drug interactions,and formulate safe and reasonable combination scheme for medication.