| 张红旭,牛立营,杨庆,郭辉.基于JCI国际医院认证理念探讨临床药学监护报告纳入医院病案管理的意义[J].中国药事,2017,(2):230-234 |
| 基于JCI国际医院认证理念探讨临床药学监护报告纳入医院病案管理的意义 |
| On Signifcance of Bringing Clinical Pharmaceutical Care Reports into Hospital Medical Record Management Based on JCI International Hospital Accreditation Ideas |
| 投稿时间：2016-07-30 |
| DOI：10.16153/j.1002-7777.2017.02.022 |
| 中文关键词: 国际医院认证标准 国际联合委员会 认证 理念 药学监护报告 病案 管理 |
| 英文关键词: hospital accreditation standards Joint Commission International (JCI) accreditation ideas pharmaceutical care report medical record management |
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| 中文摘要: |
| 目的：用国际联合委员会（JCI）国际医院认证理念，探讨临床药学监护报告纳入医院病案管理的意义。方法：通过JCI国际医院认证基本理念，阐述了临床药师药历是临床药师分析、评估病人用药的原始医疗文件，其核心是药学监护报告。通过临床实例说明药学监护报告在病人安全、合理、有效、经济用药过程中的重要性，进而提出药学监护报告纳入医院病案管理的意义。结果：药学监护工作是临床工作重要的组成部分，药历及其监护报告是重要的医疗文件，应当纳入医院病案管理范畴。结论：药学监护报告纳入医院病案管理对于规范医生与临床药师交流、提高病人用药质量具有重要作用。 |
| 英文摘要: |
| Objective: To discuss the signifcance of bringing clinical pharmaceutical care reports into hospital medical record management based on JCI international hospital accreditation ideas.Methods: Based on the basic idea of JCI hospital accreditation, this paper expounded that the clinical pharmacist medication records were the original fle the clinical pharmacists could use to analyze and assess the drug use of patients, and the core of medication records was the pharmaceutical care reports. The importance of the pharmaceutical care reports in process of safe, reasonable, effective and economic drug use of patients was showed through the clinical cases, and then the significance of including the pharmaceutical care reports in the hospital medical record quality management was put forward.Results: Pharmaceutical care is an important part of the clinical work, and medication records and care reports are important medical documents. Therefore medication records should be included in the category of medical record quality management.Conclusion: Bringing pharmaceutical care report into the hospital medical record management plays an important role in regulating the communication between doctors and clinical pharmacists and improving the quality of rational use of drugs for patients. |
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