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目的为更好规范我院处方的标准化管理,提高医疗服务质量,保障临床合理用药。方法随机抽取我院2010年1月至2010年6月儿科、妇科、内科、眼科、耳鼻喉科的门诊处方(西药处方)各1000张,共5000张处方整理后,依据卫生部《处方管理办法》以及《河南省处方管理办法实施细则》对1206张不合理处方进行回顾性分类统计分析。结果 5000张处方中存在不同问题的处方数为1206张,占抽查处方总数的24.12%。不合理处方主要表现在书写不规范,药品适应证与诊断不符,无指征使用抗菌药物,用法用量不当,重复给药等方面。结论由此可见,我院门诊处方书写的准确、完整、无误上还存在较多问题。加强医师处方书写规范及临床合理用药知识的学习,把好处方审核质量关,是提高处方书写质量和临床合理用药的有效整改措施。
The purpose is to better standardize the standardized management of our hospital prescriptions, improve the quality of medical services, to protect the clinical rational use of drugs. Methods A total of 1000 outpatient prescriptions (prescriptions for western medicine) in pediatrics, gynecology, internal medicine, ophthalmology and otolaryngology were randomly collected from January 2010 to June 2010 in our hospital. After a total of 5000 prescriptions were sorted out, according to the “prescription management approach ”And“ Henan Province, the implementation details of the prescription management approach ”to retrospective classification and statistical analysis of 1206 unreasonable prescriptions. Results The number of prescriptions with different problems in 5000 prescriptions was 1206, accounting for 24.12% of the total number of spot checks. Irrational prescription mainly in the non-standard writing, drug indications and diagnostic discrepancies, no indications for the use of antimicrobial agents, dosage usage, repeated administration and so on. Conclusions This shows that there are still many problems on the accurate, complete and error-free writing of outpatient prescriptions in our hospital. To strengthen the learning of prescription prescriptions and clinical rational drug use by doctors and to examine the quality of good prescriptions is an effective rectification measure to improve the quality of prescription writing and clinical rational drug use.