住院病历医嘱用药点评及结果分析

Reviews and analysis of Medication Orders Inpatient Medical Records in our hospital

目的通过对我院病区医嘱用药的点评分析,有效提高了临床合理用药水平。方法以《医院处方点评管理规范(试行)》和卫生部办公厅关于做好全国抗菌药物临床应用专项整治活动的通知要求为依据,2014年平均每月抽查出院病历80份,对抗菌药物使用的基本概况、不合理用药的具体表现进行分析。结果共点评了病历960份,其中370份使用了抗菌药物,其平均使用率为38.5%。不合理用药有115份,合理用药率为88.0%。不合理用药主要包括围手术期预防用抗菌药物不合理、治疗用抗菌药物用法用量不合理、药物配伍不合理、无指征用药等。结论点评能使抗菌药物及其他药物使用趋于合理。

Objective TO effectively improve the level of clinical rational drug use through the analysis of doctor＇s prescription comment in our hospital. Methods According to the ＂Specification for hospital prescription review management（Trial）＂and ＂Notice of the general office of the Ministry of health on the clinical application of antibacterial drugs special rectification activities＂, we checked 80 medical records the average monthly in 2014, formulated and filled out the form, analyzed the basic situation of antibacterial drug use, and the specific manifestations of irrational drug use. Results Commented on 960 medical records, of which 370 copies used antibiotics, the average utilization rate was 38.5%. The number of the non-rational use of drugs was 115, reasonable use rate was 88%. Irrational drug use involved the unreasonable preventive use of antibiotics in surround operation period,unreasonable usage of antibacterial drugs, unfavorable of drug compatibility, no indications of medication,not in strict accordance with the provisions of the drug usage and dosage of drug use and so on. Conclusion Comments could make the use of antibiotics and other drugs reasonable.