目的：了解住院患者的临床用药状况，规范病区用药医嘱，提高临床合理用药水平。方法：随机抽取长治医学院附属和济医院2013年960份住院患者病历，根据《医院处方点评管理规范（试行）》《处方管理办法》等相关规定，对病历用药医嘱的合理性进行分析、评价。结果：所抽查的960份住院患者病历中，用药合理医嘱有864份（占90％），有96份（占10％）存在不同程度的不合理用药现象。不合理用药主要包括用药与临床诊断不符、用法与用量不合理、给药途径错误、联合用药不合理、溶媒选择不合理等方面。结论：通过对住院患者用药医嘱的点评，分析和评价临床用药的合理性，可监督和指导临床合理用药，保障患者的用药安全，提高医疗质量。%OBJECTIVE:To investigate the clinical medication in the inpatients of Changzhi Medical College Affiliated Heji Hospital so as to standardize medication orders and improve clinical rational use of drugs. METHODS:A total of 960 medical re-cords of the inpatients from Changzhi Medical College Affiliated Heji Hospital in 2013 were randomly collected for analysis and evaluation with regard to the rationality of the medication orders in accordance with“Hospital prescription review management stan-dard(trial)”,“Prescription management method”and other related regulations. RESULTS:Of the 960 medical records reviewed, 864 (90%) were rational versus 96 (10%) nonrational to different degree. The irrationality manifested as inconformity between drugs and clinical diagnosis,irrational usage and dosage,improper route of administration,irrational drug combination or irrational choice of solvents etc. CONCLUSIONS:Clinical rational drug use can be monitored and guided through the review of medication orders and the analysis and evaluation on the rationality in clinical medication and which can help ensure patients’medication safe-ty and improve the quality of medical treatment.
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