临床药师查房记录实践王宜文* ,李国成,伍俊妍(中山大学孙逸仙纪念医院药学部,广州市 510120 ) 中图分类号 R 95文献标识码 A文章编号 1001 - 0408 ( 2010 ) 18 - 1725 - 03 摘要目的:调整临床药师查房记录的书写,促进合理用药。方法:参考国内、外药历模型以及《中国药历书写原则与推荐格式》,借鉴医师病程记录的格式,紧紧围绕药学服务的工作重心,针对患者病情变化和相应用药方案的调整查房记录的书写, 并以心内科一患者为例进行说明。结果:初步建立了以首页、查房记录表两部分组成的查房记录。结论:所建查房记录涵盖了临床药学服务所需的必要医学信息,记录简明、可操作性强,凸显临床药师的工作特点,并促进临床药师与医师更好的交流,在一定程度上能适应目前临床药学工作的需要。关键词临床药学;临床药师;查房记录 Clinical Pharmacists ’ Records of Ward Round WANG Yi-wen , LI Guo-cheng , WU Jun-yan ( Dept. of Pharmacy , Sun Yat- sen Memorial Hospital of Sun Yat- sen University , Guangzhou 510120 , China ) ABSTRACT OBJECTIVE : To establish a new pattern of ward round record for clinical pharmacist and rational use of drug. METHODS : The new pattern of ward round record was established according to domestic and foreign history pattern , The Princi-ple and Proposed Pattern of Clinical Medication History in China , disease course record. This new pattern focused on patients ’ dis-ease and medication changes. A case of cardiovascular department was taken as example. RESULTS : Established ward around re-cord contained two parts , . first page and record chart. CONCLUSION : Established pattern is concise and practical and covers es-sential medical information. It munication more easily between pharmacist and doctors and meets the needs of clinical pharmacy practice. KEY WORDS Clinical pharmacy ; Clinical pharmacist ; Ward round re
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