医院门诊中药处方调查分析

Investigation and Analysis of Traditional Chinese Medicine Prescriptions in Hospital Outpatients

目的:调查分析医院门诊中药处方。方法:随机选取我院2017年1月1日~2018年12月31日开具的中药饮片处方1920张,进行分析点评。结果:在1920张中药处方中,2017年不规范中药处方138张,2018年有95张,临床诊断不规范或未写诊断、处方书写缺项、临床诊断与用药不符、用法用量选择不当、脚注遗漏、医师未签字或标明日期发生率较高。结论:2018年不规范处方明显少于2017年,中药处方的规范性、医师的业务水平还需提升。

Objective:To investigate and analyze the prescription of traditional Chinese medicine in hospital outpatients. Methods:A total of 1,920 prescriptions of Chinese herbal medicines prescribed from January 1, 2018 to December 31, 2018 were randomly selected for analysis. Results:In the 1,920 prescriptions of traditional Chinese medicine, 138 were unqualified for 2017, and 95 for 2018, with higher incidences of unqualified clinical diagnosis or lack of diagnosis, missing information in prescriptions, medication inconsistent with clinical diagnosis, improperly selected usage or dosage, missing footnote or physician signature or no date. Conclusion:The number of unqualified prescriptions in 2018 is significantly lower than that in 2017, and attention should be paid to improve the normative prescription of traditional Chinese medicine and professionalism of physicians.