基于临床药师工作实践构建电子药历管理平台

目的：构建高效实用的电子药历管理平台，协助临床药师开展药学服务，保障医疗质量和医疗安全。方法：电子药历管理平台采用C++语言编写，尝试与电子病历系统实现无缝对接；根据患者在院流程设置七大药学服务模块，实现患者的全程化药学管理，并制定了患者药学监护的分级管理制度。结果：药历和病历系统的融合真正实现了医药护数据的无缝对接和共享，能让医护及时了解相关药学建议，促进合理用药；药学监护的全流程化则确保了患者药学监护的连续性和完整性；而药学监护分级管理制度则让临床药师的工作有的放矢，在提高效率的同时突出了重点。结论：该电子药历管理平台的构建不仅促进了我院临床药学工作的发展，而且为我国临床药学电子药历的规范化建设和管理提供参考，对医疗质量和医疗安全的保障起到了积极作用。

Construction of electronic medication record management platform based on the clinical pharmacist work practice

OBJECTIVE To construct an effective and practical management platform for electronic medication record to assist clinical pharmacists in the pharmaceutical services, ensure medical quality and medical safety.METHODS Electronic medication record management platform was designed by C++ machine language. It was seamlessly combined with the electronic medical record system, integrated with the classification and management system of pharmaceutical care for patients, and constituted by seven pharmacy service modules according to the procedure of patient in a hospital.RESULTS This management platform realized the data sharing for physician, nurse and pharmacist, and improved the efficiency of the clinical pharmacists work. Meanwhile, it ensured the continuity and integrity of the pharmaceutical care for patients during the whole process.CONCLUSION This electronic medication record management platform not only promotes the development of clinical pharmacy in our hospital, but also provides a reference for the standardized construction and management of clinical pharmacy electronic medication record in China, and plays a positive role in the protection of medical quality and medical safety.