临床药师在电子病历中书写药学查房意见的临床实践

Clinical Practice of Clinical Pharmacists Writing Pharmacy Rounds Opinion in Electronic Medical Records

目的:探索临床药师以在电子病历中书写药学查房意见作为切入点开展药学服务的内容与体会。方法:阐述电子病历中书写药学查房意见的格式、内容、时机、方式、重点、效果以及对典型案例进行分析。结果:临床药师坚持深入临床直接面对患者,发挥药学专长,参与个体化用药,已逐渐成为医院合理用药中不可缺少的成员。结论:临床药师在病历中书写药学查房意见,可成为临床药师深入临床开展药学服务的切入点,体现临床药师的价值。

OBJECTIVE：To explore the content and experience of clinical pharmacists developing pharmaceutical care with writing pharmacy rounds opinion in electronic medical record as the breakthrough point.METHODS：The writing of pharmacy rounds opinion in electronic medical record were interpreted in respects of format,content,timing,manner,focus,effects and typical case.RESULTS：Clinical pharmacists adhered to directly face the patient in the clinic,full played professional pharmacy skill and participated in personalized medication.They gradually became indispensable member of rational drug use in the hospital.CONCLUSIONS：It becomes the entry point of developing pharmaceutical care in-depth that clinical pharmacist write pharmacy rounds opinion in medical record,which reflects the value of clinical pharmacists.