某三甲医院门诊处方点评结果与分析

Evaluation and analysis of outpatient prescriptions in a tertiary hospital

目的:通过门诊处方点评工作,探讨处方规范化管理方式,为临床合理用药提供参考。方法:每月从某院门诊处方中分层、随机抽取120张(共计2 280张)进行点评,对不合理处方中存在的问题进行归纳、汇总,并对点评结果进行统计分析。结果:抽取的该院门诊处方中处方合格率为95.5%,不合理处方有103张,主要表现为:未写临床诊断或临床诊断书写不全的37张(35.92%)、用法用量不适宜27张(26.21%)、超过7 d用量15张(14.56%)等。结论:通过处方点评工作,发现该院门诊不合理用药现象还较为严重,应建立完善的处方管理制度,通过多种措施,促进临床合理用药。

Objective： To explore the best way to standardize the management of prescription by reviewing out-patient prescription so as to provide a reference basis for clinical regular drug use. Methods： One hundred and twenty prescriptions were randomly selected from outpatient prescriptions each month. The problems existed in irrational prescriptions were summarized and the evaluation results were statistically analyzed. Results： The qualified ones in all prescriptions accounted for 95.5% and there were 103 unreasonable prescriptions including 37 prescriptions（35.92%） without clinical diagnosis or with incomplete clinical diagnosis, 27 prescriptions（26.21%） with unsuitable usage and dosage and 15 prescriptions（14.56%） with dosage over 7 days and so on. Conclusion： Outpatient irrational drug use in this hospital is more serious and a complete prescription management system should be established by a variety of measures so as to promote rational use of drugs in clinic.