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目的对我院住院病历进行分析,为临床合理用药提供参考。方法随机抽查2010年全年住院病历5380份,并对其中不合理用药现象进行统计分析。结果 5380份住院病历中,其中不合理用药病历243份,占总病历数的4.52%。结论住院病历用药基本合理,但仍存在用药时间不合理、药物选择不合理、药物用法不合理、用药剂量不合理、用药途径不合理等。因此,药师应主动和医师加强交流,促进合理用药。
Objective To analyze the inpatient medical record of our hospital and provide a reference for clinical rational drug use. Methods A random sample of 5,380 in-patient medical records in 2010 was made and statistical analysis of the phenomenon of irrational drug use was made. Results 5380 in-patient medical records, including irrational medication 243 cases, accounting for 4.52% of the total medical records. Conclusion The medical record of hospitalized patients is basically reasonable, but there are still some problems such as unreasonable medication time, unreasonable drug selection, unreasonable drug usage, unreasonable dosage and irrational route of medication. Therefore, pharmacists should take the initiative to strengthen exchanges with the physician to promote rational drug use.