临床信息的收集与药物治疗

Collection of clinical information and drug treatment

临床信息是通过询问病史和症状、做体格检查和辅助检查来获得的,它是制订和修改药物治疗方案的依据,也是开展药学服务的指标及进行用药指导的前提。本文阐述了药物治疗所需的临床信息、临床信息的意义、临床信息收集不当的表现,并分析了产生临床信息收集不当的医师因素和病人因素。

Clinical information was collected by disease history taking, physical examination and auxiliary examination, which could provide the references for making and changing the schedule of drug treatment. It was the prerequisite for pharmaceutical care and carrying out the drug instruction. This paper described clinical information of drug treatment, significance of clinical information and the common mistakes in collection of clinical information. The causes of mistakes in collection of clinical information induced by doctors and patients were analyzed.