摘要
目的探讨通过信息技术实现医嘱前置审核中的应用。方法依靠合理用药知识库及医嘱审核规则建立合理用药前置审核系统,采用信息系统和人工审核相结合的方式,对医嘱进行前置审核。比较前置审核前后的2016年8月与2017年8月同期的医嘱合格率。结果审核率从25.16%达到100%,审核数量显著提高;医嘱合格率从97.81%上升至99.87%,差异有统计学意义(P<0.01)。结论应用医嘱前置审核,可有效提高医嘱审核效率与质量。
Objective To discuss the application of intellectual technology in instruction pre-checking system.Methods build up the instruction pre-checking system on the basis of rational drug use repository and the regulation of instruction checking and use the system in august 2017. Thencompare the outcome with the data in august 2016 when instruction checking was carried out artificially by pharmacists.Results The audit rate increased from 25.16% to 100%. It was a great improvement. What is more,the quality of the instructions improved a great deal,from 97.81 percent to 99.87 percent,and there was a statistical significanct difference（P0.01） between 2016 and 2017.Conclusion Intellectual technology used in instruction pre-checking system could promote instruction quality.
作者
王欣
仇叶龙
李小莹
闫素英
郭景仙
赵国光
Wang Xin;Qiu Yelong;Li Xiaoying;Yan Suying;Guo Jingxian;Zhao Guoguang(Xuanwu Hospital, Capital Medical University, Beijing 100053, China)
出处
《中国病案》
2017年第12期54-56,共3页
Chinese Medical Record
基金
首都医科大学校长基金(16GLY18)
关键词
信息技术
医嘱
前置审核
Intellectual technology
Doctor＇s instruction
Pre-checking
