借助电子药历 提高临床合理用药质量

目的对临床药师所制作的电子药历进行分析,探讨电子药历对临床药师工作的辅助作用。方法采用Excel软件对2008年10月～2009年12月期间临床药师所制作的电子药历,其中临床干预所涉及药物、临床医师结合患者情况对于临床药师的临床干预的采纳情况进行分析汇总。结果临床药师应用电子药历管理系统制作电子药历133份。其中针对药物治疗优化,药品不良反应/事件,特殊人群用药,药物相互作用,药物不合理配伍的药历分别有30份、25份、19份、8份、2份以及教学药历49份。对于临床药师在对患者提供的药学监护过程中所提出的干预建议,临床医师采纳68条,表示关注18条,未采纳19条,采纳率为64.76%（68/105）。结论临床药师通过建立电子药历,对提高临床合理用药水平起到了很好地促进作用,并得到了临床医师的认可,但是临床药师在药物相互作用,药物不合理配伍等方面需加大关注力度。

To Promote the Pharmaceutical Care Service Quality by Electronic Medication Record

Objective To analyze and evaluate the electronic medication record for clinical pharmacists work. Methods The electronic medication records were analyzed by Excel software. Results The 133 electronic medication records were accomplished by electronic medication record management system in which drug therapy optimization,adverse drug reaction/event,special populations of drug medication records,drug interaction,unreasonable drug compatibility were respectively 30,25,19,8,2. The proposed recommendations of clinical pharmacist intervention in pharmaceutical care were adopt and concern ed by clinicians was 68 and 18 respectively. Conclusion Clinical pharmacist promote the pharmaceutical care service quality by electronic medication record establishment and the clinical pharmacist＇s work has been recognized by clinicians,but the clinical pharmacist should pay more efforts on drug interactions,drug unreasonable compatibility.