请各位前辈斧正

小赵药师 · 发表于 2011-4-20 11:32:15

要上等级，我刚受命开展临床药学工作，要做的工作包括临床药师（药历、病例分析、医嘱审核、用药知识宣传栏、药讯、药事咨询记录、处方点评表、处方实际点评及公示、指导临床正确用药PDCA）及抗菌药物整大块（含实施细则的制定及制度、职责等、I类切口合理使用PDCA及孕期、哺乳期、细胞毒、激素类使用管理），另外还负责药品采购大块事宜（含执行、网上采购、保管复核、价格更正、账务验收），还得去药剂科每月值2个夜班，其它细碎的工作就不说了。所以压力很大，想弄一份简单一点的药历模板，现在上传，请各位帮忙出点子，是否可行，谢谢
住院药历
            药历号_________
表1 住院药历首记录
姓名________性别____出生日期_______________住院号____________病区_____床号_____
体重_____身高_____联系方式_____________职业_____地址___________________________
入院时间____________首记录申诉者__________记录日期__________
（1）既往肝功能异常者（异常项）__________________________________________________
（2）既往肾功能异常者（异常项）_________________________________________________
（3）个人饮、用习惯及用量
乙醇（酒精、量）茶烟
（量）咖啡饮水（量）荤素酸辣咸化妆品

（4）既往用药史（包括OTC药品）
药品名称剂量与用法使用日期使用期（天）用药原因（疾病）

（5）药物过敏史
可疑致敏药品过敏症状治疗过敏症状药品现在有无遗留症状

（6）家族性药物不良反应史_______________________________________________________
（7）既往用药依从性_____________________________________________________________
（8）辅助检查：

表2 药历住院记录
姓名__________性别_____年龄_____住院号_________病区_____床号______体重_____
身高______入院日期__________诊断_____________________
            日期
药品及用法用量

备注：原疾病症状：_______________________________________________________________过敏及不良反应症状：___________________________________________________________
√：当日使用；×或不标记：停药及未用；a在药历中以红色标记，表示药物不良反应及过敏症状出现日；b在药历中以蓝色标记，表示过敏减轻日；c在药历中以绿色标记，表示药品起效日，d在药历中以黄色标记，表示药师提示需改进的治疗方案。

表3  药历出院记录
姓名__________性别___年龄____住院号_________病区____床号_____体重____身高_____
出院日期_________入院诊断_________________出院诊断_____________________________
用药评价：_____________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
经济评价：_____________________________________________________________________
治疗期间总金额日均金额
抗菌药物
其他用药
疗效：
药物治疗效果药物不良反应不良反应处理
病人感觉
药师评价
出院后用药建议：
（1）治疗用药的正确用法、保存方法、可能的药物不良反应：_________________________
______________________________________________________________________________________________________________________________________________________________
（2）今后应避免使用的药物及饮食方面注意：______________________________________
_______________________________________________________________________________
（3）告示患者用药请咨询药师：__________________________________________________
用药总结：_____________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________