2019年住院中药饮片处方点评分析

Review and Analysis of Inpatient Chinese Herbal Decoction Pieces in 2019

目的点评分析住院中药饮片处方,了解处方结构及变化特点,找出存在的问题,以期为临床合理用药提供指导和帮助。方法随机抽取2019年1月—2019年12月病历715份,涉及中药饮片处方1542张,对住院中饮片处方进行点评,并对点评结果进行回顾性汇总分析。结果我院住院中药饮片处方平均药付数6.54付,平均药味数10.84味,平均每剂金额34.9元,平均合格率为71.33%,主要不合理问题为辨证与用药不相符、未体现辨证论治等。结论住院中药饮片处方结构较为合理,但合格率有待提升,应当加强病程辨证相关信息的书写管理,以提升病历及处方质量。

Objective To comment and analyze Chinese herbal decoction pieces in hospital medical records,to understand the structure and change characteristics of the prescription,and to find out the existing problems,so as to provide guidance and help for rational clinical use of medicine.Methods A number of medical records from January to December 2019 were randomly selected,and the prescriptions of Chinese herbal decoction pieces in the medical records were reviewed,and the review results were retrospectively summarized and analyzed.Results In the inpatient record of the hospital,the average prescription amount of Chinese herbal decoction pieces was 6.54,the average taste amount was 10.84,the average amount per dose was 34.9 yuan,and the average pass rate was 71.33%.The main unreasonable problems are the inconsistency between syndrome differentiation and medication,and the failure of syndrome differentiation and treatment.Conclusion The prescription structure of inpatient Chinese herbal decoction pieces is reasonable,but the qualified rate needs to be improved.In order to improve the quality of medical records and prescriptions,it is necessary to strengthen the written management of information related to syndrome differentiation.