2010—2013年焦作市第二人民医院住院病历用药医嘱分析

Reviews and Analysis of the Medication Orders in Inpatient Medical Records in Our Hospital from 2010 to 2013

目的:通过对焦作市第二人民医院(以下简称"我院")住院部病历用药医嘱进行分析,为提高临床合理用药水平提供参考依据。方法:抽查2010年2月—2013年12月我院住院病历共1 410份,对医嘱和用药情况进行分析。结果:抽查的1 410份病历中,不规范医嘱89份,占6.31%;不合理用药医嘱253份,占17.94%。结论:我院病历医嘱存在较多不合理状况,需相关部门加大监督检查力度,提高临床合理用药水平。

OBJECTIVE：To analyze the medication orders in the inpatient medical records in Jiaozuo Municipal Second People＇s Hospital （hereinafter referred to as ＂our hospital＂） in order to improve the leve of rational use of drug. METHODS： 1 410 medical records were sampled in our hospital from February 2010 to December 2013 for analysis of the medical order and drug use. RESULTS： Of the total 1 410 medical records sampled, 89 （6.31%） were nonstandard and 253 （17.94%） were irrational in drug use. CONCLUSIONS： Multiple irrational drug use phenomena were noted in the medication orders in our hospital, therefore, it is important for the concerned departments to strengthen supervision so as to improve the level of rational use of drug.