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处方是医生在疾病诊治过程中所出具的兼有医疗、经济、法律、技术等多重作用的书面药学文书。其书写质量的优劣,不仅体现出处方者本人的诊疗技术水平和敬业态度,也是评价一个科区乃至一家医院整体水准及内在质量的重重参考依据。长期以来,基层医院普遍存在重诊疗水平、轻医疗文书现象,对处方书写缺乏严格的要求和考核,不少医师养成了处方书写随便、马虎的陋习。如江西省卫生厅对57家省和地区级医院抽查,门诊处方的合格率低于50％者达20％之多。1993年我们在创建等级医院过程中,结合我院建院时间较长、设置床位较多、用药量大且品种较庞杂、各级医生处方水平相差较悬殊、处方质量较难把握的特点,通过对当年
Prescriptions are written medical documents issued by doctors in the process of diagnosis and treatment of diseases, which have multiple functions of medical treatment, economy, law, and technology. The quality of its writing not only reflects the prescriber’s own diagnosis and treatment technology level and dedication, but also is a reference for evaluating the overall level and intrinsic quality of a department and even a hospital. For a long time, primary hospitals generally suffer from serious diagnosis and treatment and light medical instruments. There are no strict requirements and examinations on prescription writing, and many doctors have developed habits and sloppy prescriptions. For example, the Provincial Department of Health of Jiangxi Province conducted spot checks on 57 provincial and regional hospitals, and as many as 20% of the eligible patients for the outpatient prescriptions were less than 50%. In 1993, during the process of building a graded hospital, we used the characteristics of long time, large number of beds, large quantities of drugs, and complicated varieties, different levels of doctors’ prescription at various levels, and difficult to grasp prescription quality. For the year