临床药学查房录的药学实践

目的：探讨临床药学查房录对临床用药的指导意义。方法：通过调取江苏省扬州市第一人民医院2014年7月至2015年12月临床药师书写查房录的病历212份，使用Excel软件统计分析临床药学查房录书写的原因、内容及结果。结果：临床药师书写临床药学查房录涉及的成因和内容主要为用药方案的调整（62.0%）及药物不良反应应对（14.9%）。医师接受临床药学查房建议的程度为87.2%。结论：临床药师参与药学查房多以口头建议、非书面交流为主，临床药学查房录的书写不仅弥补了应召干预、追溯乏力的不足，而且对临床合理用药具有书面指导意义，更具执行力。

Pharmacy Practice of Clinical Pharmacy Records of Ward Round

Objective: To investigate the guiding significance of clinical pharmacy records of ward round for clinical drug use. Methods: A total of 212 medical records with clinical pharmacy records of ward round written by clinical pharmacists from July 2014 to December 2015 in Yangzhou No.1 People''s Hospital of Jiangsu Province were selected. Causes, contents and results of the clinical pharmacy records of ward round were analyzed using Excel software. Results: The main causes and contents of clinical pharmacy records of ward round written by clinical pharmacists were drug adjustments (62.0%) and responses to adverse drug reactions (14.9%). The physicians'' acceptance rate of the suggestions from the clinical pharmacy records of ward round was 87.2%. Conclusion: Clinical pharmacists participated in pharmacy ward round in the way of verbal suggestions and non-written communication. Clinical pharmacy records of ward round not only compensated for the weakness of call interventions and traceability, but also had written guiding significance and more executive force for clinical rational drug use.