门诊处方点评与不合理处方分析_高立娜.pdf

620 中国药事 2016 年 6 月 第 30 卷 第 6 期 ·合理用药 · 门诊处方点评与不合理处方分析 高立娜，翟丽杰，张静 （吉林大学第二医院，长春 130041） 摘要 目的：为减少我院门诊不合理处方数量、规范医生开具处方提供参考。方法：对 2015 年上半年 结果： （1-6 月）门诊处方点评数据进行回顾性分析。 共点评 2015 年上半年门诊处方 516688 张，发现 不合理处方 4746 张，平均合格率为 99.08%。诊断与用药不相符处方 2572 张，单次剂量不规范处方 935 张，给药方式不正确处方为 899 张，给药频次不正确和超数量开药处方分别为 331 张和 9 张。结论：我 院需进一步深入开展处方点评工作，完善处方点评方法和制度，加快合理用药软件的开发，促进临床合 理用药。 关键词： 门诊处方；处方点评；合理用药 中图分类号：R95; R969.3 文献标识码：A 文章编号： 1002-7777(2016)06-0620-05 doi:10.16153/j.1002-7777.2016.06.018 Review of Outpatient Prescriptions and Analysis of Irrational Prescriptions Gao Lina, Zhai Lijie, Zhang Jing (The Second Hospital of Jilin University, Changchun 130041, China) Abstract Objective: To provide references for reducing the number of irrational prescriptions and standardizing the prescription of doctors. Methods: The data of outpatient prescriptions in first half of 2015 (January-June) were retrospectively analyzed. Results: Totally 516688 prescriptions were checked, and 4746 irrational outpatient prescriptions were found. The average pass rate of prescription was 99.08% during the first half of 2015. There were 2572 of mismatch of diagnosis and medication, 935 of inappropriate single dose, 899 of incorrect administration, 331 of incorrect administration frequency and 9 of over-quantity of prescription. Conclusion: The hospital needed to deeply develop the work of prescription review and software of prescription automatic screening system, so as to promote rational drug use. Keywords: outpatient prescription; prescription audit; rational drug use 处方点评是指对门诊处方、住院用药医嘱的 上半年处方点评结果进行分析，以期进一步规范处 用药合理性进行评价，同时将结果以一定的方式反 方，促进合理用药。 馈给处方者，并对不合理用药进行干预的系列工作 1 资料与方法 [1] [2] 1.1 资料 。《医院处方点评管理规范（试行）》 （以下 简称《规范》）中明确要求