2015-2016年门诊处方点评结果分析

Analysis of Comment Results of Outpatient Prescription during 2015 and 2016

目的对门诊处方进行点评分析,提出应对措施,促进临床合理用药。方法抽取2015年1月至2016年12月门诊处方2400张,采用回顾性分析方法对其进行点评汇总。结果筛选出不合理处方308张,占抽查处方总数的12.83%。其中开具处方临床诊断书写不全的处方64张,占不合理处方数的20.78%;医师未按照抗菌药物临床应用管理规定开具抗菌药物处方48张,占不合理用药处方数的15.58%;药品用法用量不宜的处方112张,占不合理用药处方数的36.36%;重复用药处方28张,占不合理用药处方数的9.10%;门诊处方超过7日用量未注明理由的处方56张,占不合理用药处方数的18.18%。结论医院应加大对临床医师的培训及考核力度,临床药师可通过到临床科室探讨,面对面进行反馈,加强与临床医师的沟通,促进临床合理用药,提高医院整体医疗质量,提高门诊处方的合格率,促进临床合理用药。

Objective to comment and analyze outpatient prescriptions and put forward countermeasures to promote rational clinical medicine application. Methods choose 2400 outpatient prescriptions from January 2015 to December 2016, comment and analyze them with reviewing method. Results among them, there were 308 irrational prescriptions, accounting for 12.83% of total, including 64 prescriptions with incomplete writing of clinical diagnosis, accounting for 20.78% of irrational prescriptions, 48 prescriptions with prescribing antibacterials disobeying clinical application management rules of antibacterial drugs, accounting for 15.58%, 112 prescriptions with unsuitable usage and dosage of medicine, accounting for 36.36%. 28 were repeat prescriptions, accounting for 9.10%, 56 prescriptions without reason for over 7 days dosage, accounting for 18.18%. Conclusion hospital should strengthen training and assessment of clinicians, Clinical pharmacists should discuss with clinical departments, feedback face to face, strengthen communication with clinicians, promote clinical rational medicine application, improve overall medical quality, and qualified rate of out-patient prescription, and promote rational clinical medicine application of hospital.