Objective: the experiment will strengthen the result analysis for the management of archived medical records in the pharmacy department, better put forward suggestions for the development of the work of the pharmacy d...Objective: the experiment will strengthen the result analysis for the management of archived medical records in the pharmacy department, better put forward suggestions for the development of the work of the pharmacy department, cooperate with the work content of the pharmacy department, clinical department and medical record management room, and improve the rationality of medication for patients. Methods: taking the archived medical records of the experimental pharmacy department as the main body of the investigation, the medication situation of 300 archived medical records from July 2019 to June 2020 was intercepted in the time period, and the medication situation was timely fed back to the clinical department. Results: from the perspective of all medical records, there were 7 unreasonable medical records and 11 dissenting medical records, which were caused by faulty medical orders. In addition, the number of unreasonable medical orders in the first half of 2020 was significantly lower than that in the second half of 2019, indicating that the medical orders were more accurate after the strengthening of comment management. In the cases that did not conform to the guidelines for clinical application of antibiotics, there were 2 cases of irrational prophylactic drug use, 3 cases of unindicated drug use and 2 cases of unsuitable usage and dosage. Conclusions: to strengthen the comment management of archived medical records is conducive to ensuring the medication safety of patients, and the problems found can be discussed centrally, thus improving the participation of pharmacists and strengthening the connection between departments.展开更多
文摘Objective: the experiment will strengthen the result analysis for the management of archived medical records in the pharmacy department, better put forward suggestions for the development of the work of the pharmacy department, cooperate with the work content of the pharmacy department, clinical department and medical record management room, and improve the rationality of medication for patients. Methods: taking the archived medical records of the experimental pharmacy department as the main body of the investigation, the medication situation of 300 archived medical records from July 2019 to June 2020 was intercepted in the time period, and the medication situation was timely fed back to the clinical department. Results: from the perspective of all medical records, there were 7 unreasonable medical records and 11 dissenting medical records, which were caused by faulty medical orders. In addition, the number of unreasonable medical orders in the first half of 2020 was significantly lower than that in the second half of 2019, indicating that the medical orders were more accurate after the strengthening of comment management. In the cases that did not conform to the guidelines for clinical application of antibiotics, there were 2 cases of irrational prophylactic drug use, 3 cases of unindicated drug use and 2 cases of unsuitable usage and dosage. Conclusions: to strengthen the comment management of archived medical records is conducive to ensuring the medication safety of patients, and the problems found can be discussed centrally, thus improving the participation of pharmacists and strengthening the connection between departments.
