摘要
目的了解南华大学附属医院《处方管理办法》的贯彻落实情况,对比分析手写处方和电子处方书写规范度的差异,为规范处方使用提供依据。方法采用随机抽样调查的方式,依据处方点评标准,对南华大学附属第一医院、附属第二医院新院、附属第二医院老院处方规范率及不规范表现进行统计分析。采集电子处方和手写处方的不规范数据,分析比较不合理差异。结果经过抽样调查,南华大学附属第一医院的处方(全部为电子处方)不规范率最低,为12.92%;附属第二医院新院的处方(部分电子处方)不规范率较高,为22.70%;附属第二医院老院的处方(全部为手写处方)不规范率最高,为35.89%;经过多个样本比较的Friedman M检验分析,三组数据差异有统计学意义(P<0.05)。电子处方中不规范处方占13.38%,远远低于手写处方不规范率34.29%,且差异有高度统计学意义(P<0.01)。手写处方中的不规范表现较多,集中体现为前记、规格、药名错误,药师未执行双签名规定等方面,而电子处方不规范的因素比较单一,主要是婴儿处方未写明体重或日、月龄。结论医院应该加强处方书写方面的管理力度,提高药剂人员的素质,强化医院的信息系统,使手写处方逐步往电子处方过渡,促进处方书写规范化。
Objective To understand the implement situation of Prescription Management Approach in the Affiliated Hospital of University of South China and to comparatively analyze the writing non-standardization degree differences between hand- written prescription and electronic prescription, in order to provide evidence for the standardization of prescription. Methods The randomly selected prescriptions, from the First Affiliated Hospital, the New Second Affiliated Hospital and the Old Sec- ond Affiliated Hospital of University of South China, were retrospectively reviewed one by one and analyzed statistically ac- cording to the Prescription Management Approach. The prescriptions non-standard rate and standardization performance were captured for analyzing writing standardization degree difference between handwritten prescriptions and electronic prescriptions. Results The non-standard rates of prescriptions from the First Affiliated Hospital, the New Second Affiliated Hospital and the Old Second Affiliated Hospital was 12.92%, 22.70% and 35.89% respectively. After analyzed by the Friedman M test, the differences of the three sets of data were statistically significant （P 〈 0.05）. Non-standard writing rate of handwritten prescription was 34.29% and the electronic prescription was only 13.38%, and the difference was statistically significant （P 〈 0.01）. Moreover, the non-standardization performance of handwritten prescriptions was far more than electronic prescriptions. Handwritten prescriptions non-standardization mainly manifested the incomplete foreword, unclear drug specification, wrong drug name and no double signature so on. And the electronic prescription non-standardization factor was relatively simple and mainly included ambiguous weight and unintelligible age in the baby prescription. Conclusion It＇s necessary to strengthen the management of prescription writing and improve the quality of pharmacy staff. Furthermore, the hospital＇s information system should be redoubled to make handwritten prescriptions gradually transition to electronic prescription for promoting prescription writing standardization.
出处
《中国医药导报》
CAS
2013年第31期121-124,共4页
China Medical Herald
基金
国家自然科学基金资助项目(编号81102516)
南华大学博士启动基金项目(编号2012XQD18)
关键词
手写处方
电子处方
书写规范
Handwritten prescription
Electronic prescription
Writing standardization
