杨栋 陈楠 黄静 武天坤

摘 要 目的：探讨门诊处方常出现的问题及药师在处方审核与干预中的作用研究。方法：选取2016年1月—2017年12月的门诊处方作为基础数据，同时提取2018年1月—2019年12月提高药师审方能力和沟通能力后的门诊处方数据，分别统计每年度门诊处方出现的问题、不合理处方、不合理处方的类型等数据。对比提高药师审方能力和沟通能力前后的差别。结果：药师审方能力提高后不合理处方发生率低于干预前（P<0.05）；门诊处方主要常见问题包括超常处方、不适宜处方等；不合理处方中占比最高的是副高级及以上职称医师；药师审方能力提高后，门诊处方中超常处方、不适宜处方等常见问题发生率均有明显减少（P<0.05）。结论：门诊药师应不断提高自身业务水平，将丰富的药学实践经验、扎实的理论知识运用到处方审核与干预中。通过提高药师审方能力，门诊处方用药合理性得到有效提高，提升合理用藥水平。

关键词 不合理处方 临床医师 门诊药师 药学经验 临床诊断书写不全

中图分类号：R952 文献标志码：C 文章编号：1006-1533（2021）09-0056-04

Common problems of outpatient prescription and the role of pharmacists in prescription review and intervention

YANG Dong*， CHEN Nan， HUANG Jing， WU Tiankun

（Department of Pharmacy， the Zhengzhou Peoples Hospital， Zhengzhou 450003， China）

ABSTRACT Objective： To explore the common problems in outpatient prescriptions and the role of pharmacists in prescription review and intervention. Methods： The outpatient prescriptions from January， 2016 to December， 2017 were selected as the basic data， and the outpatient prescription data from January， 2018 to December， 2019 after the improvement of pharmacists abilities of prescription review and communication were extracted. The data of problems， unreasonable prescriptions and types of unreasonable prescriptions in each year were counted， respectively. Their differences were compared before and after the improvement of pharmacists ability of examining prescriptions and communication. Results： The incidence of irrational prescriptions was lower after the improvement of pharmacists ability of prescription review than before the intervention（P<0.05）. The main common problems of outpatient prescriptions included abnormal prescriptions， inappropriate prescriptions and so on and the highest proportion of irrational prescriptions occurred in the associate senior doctors or above. The incidence of abnormal prescriptions， inappropriate prescriptions and the other common problems in outpatient prescriptions were significantly reduced with the improvement of pharmacists ability of prescription review （P<0.05）. Conclusion： Outpatient pharmacists should constantly improve their professional level and apply their rich pharmaceutical practice experience and solid theoretical knowledge to prescription review and intervention. The rationality of outpatient prescription and the level of rational drug use can be effectively improved by the improvement of the pharmacists ability of prescription review.

KEy WORDS irrational prescription； clinician； outpatient pharmacist； pharmaceutical experience； clinical diagnosis of dysgraphia

门诊处方是药品流向的原始记录，也是患者进行药物治疗的原始记录，同时还是药师为患者发药和调配的依据[1]。处方是医师给患者开具的取药凭证，用于治疗和预防疾病，其书写质量直接关系到患者的健康和生命安全，处方作为重要的医疗文书，在医疗活动中具有法律效力。药师调剂处方、医师开具处方都应当遵循适当、经济、有效、安全的原则。药师发现处方中的疑义或问题时，应请医师重新更正或确认，及时联系处方医师。处方的审核和干预必须在药师为患者调剂处方前进行。本次研究分析2016年—2017年门诊处方常出现的问题，对不合理处方存在的原因进行统计、分析，并于2018年1月开始提高药师审方能力和沟通能力，探讨药师审方能力和沟通能力前后门诊处方用药情况，分析临床药师在处方审核与干预中的作用。……