674 份出院病历医嘱用药合理性分析.

OBJECTIVE: To investigate the medication status and rationality of discharged medical orders in Changshu the First People' s Hospital(hereinafter referred to as "our hospital "), so as to provide reference for the rational medication. METHODS: From the hospital information system, 674 discharged medical orders from Jan. 2017 to Sept. 2017 were extracted. The basic information of the medical records was counted. The doctor' s advice for each medical record were audited and critiqued. The review results were summed up and analyzed. RESULTS: The 674 cases of medical records mainly related to the medical records of the non operating department. And there were 23 482 medical orders in total and 725 medical orders of irrational medication(accounted for 3.09%). The irrational medication mainly performed as over dose(206 cases, 28.41%), improper indications(159 cases, 21. 93%) and improper selection of solvent(112 cases, 15.45%), and other problems are improper use of solvents, improper combination of drugs, repeated use of drugs and off label drug use with super instruction age section, etc. CONCLUSIONS: The rational rate of medical orders was relatively high in our hospital, yet there are still some problems. More importance are supposed to be attached to this phenomenon, and the hospital needs to strengthen the supervision of clinical rational medication. [ABSTRACT FROM AUTHOR]