Detailed rules for the implementation of prescription management measures
1. Prescription refers to the medical documents prescribed by registered medical practitioners and assistant medical practitioners (hereinafter referred to as doctors) for patients in their diagnosis and treatment activities, which are reviewed, deployed and checked by pharmaceutical professional and technical personnel (hereinafter referred to as pharmacists) who have obtained the qualifications for pharmaceutical professional and technical positions, and serve as the patient's medication certificate. Prescriptions include medical institution ward medication orders. These rules are applicable to departments and personnel related to prescription, dispensing and storage in our hospital.
Second, doctors' prescriptions should follow the principles of safety, effectiveness and economy. Prescription drugs should be sold, formulated and used by doctors.
Three, prescription writing should abide by the following rules:
(a) the patient's general situation and clinical diagnosis are clearly and completely filled in, and are consistent with the medical records.
(two) each prescription is limited to one patient.
(3) The handwriting is clear and shall not be altered; If it is necessary to modify, it should be signed at the modification place and indicate the date of modification.
(4) The name of a drug shall be written in a standardized Chinese name; if there is no Chinese name, it may be written in a standardized English name; Doctors and pharmacists shall not compile abbreviations or use codes by themselves; The name, dosage, specification, usage and dosage of drugs should be accurate and standardized, and the usage of drugs can be written in standardized Chinese, English, Latin or abbreviations, but not? Follow the doctor's advice? 、? For personal use? So ambiguous words.
(five) the patient's age should fill in the full age, the date and month age of the newborn and baby, and indicate the weight when necessary.
(six) western medicine and Chinese patent medicine can be prescribed separately, or a prescription, Chinese herbal pieces should be prescribed separately.
(seven) the prescription of western medicine and Chinese patent medicine, each drug should be listed in a new line, each prescription shall not exceed 5 drugs.
(8) Chinese herbal medicine prescription should generally be in accordance with? Jun, Chen, Zuo and Shi? The order; The special requirements for dispensing and decocting drugs are indicated in the upper right of the drugs, and brackets are added, such as wrapping cloth, frying first, dropping later, etc. Where there are special requirements for the origin and processing of the decoction pieces, it shall be indicated before the name of the drug.
(9) The usage and dosage of drugs shall conform to the conventional usage and dosage specified in the drug instructions. In case of overdose under special circumstances, the reasons shall be indicated and re-signed.
(ten) except in special circumstances, the clinical diagnosis should be indicated.
(eleven) draw a diagonal line in the blank after the prescription is issued, indicating that the prescription is finished.
(12) The signature style and special seal of the prescriber shall be consistent with the sample style kept by the hospital pharmacy department for future reference, and shall not be changed at will, otherwise it shall be re-registered.
(thirteen) the dosage and quantity of drugs are written in Arabic numerals. Dosage should use legal dosage units: weight in grams (g), milligrams (mg) and micrograms (? G), in nanograms (ng); Capacity units are liters (L) and milliliters (mL); International unit (IU), unit (u); The unit of Chinese herbal pieces is gram (g). Tablets, pills, capsules and granules are used as tablets, pills, granules and bags respectively; The solution is in rods and bottles; Ointment and cream are in the form of sticks and boxes; Injections are in sticks and bottles, and the content should be indicated; Chinese herbal pieces take dosage as the unit.
Four, registered medical practitioners in our hospital have obtained the corresponding prescription right in our hospital. Registered practicing assistant doctors have no right to prescribe in our hospital, and their prescriptions must be signed or stamped with special seals by practicing doctors in our hospital. Doctors must sign samples in the pharmaceutical administration department or put them on record with special signatures before prescribing.
V. The Pharmaceutical Affairs Management and Drug Treatment Committee and the Medical Department are responsible for training the practicing physician Yamatonokusushi in our hospital on the use and standardized management of narcotic drugs and psychotropic drugs. Medical practitioners have the right to prescribe narcotic drugs and psychotropic drugs of category I after passing the examination, and pharmacists are qualified to prepare narcotic drugs and psychotropic drugs of category I after passing the examination. Doctors may prescribe narcotic drugs and psychotropic drugs of category I in this institution only after obtaining the right to prescribe, but they may not prescribe such drugs for themselves. Pharmacists can only prepare narcotic drugs and psychotropic drugs of category I in this institution after they have obtained the qualification of narcotic drugs and psychotropic drugs of category I.
Six, the trainee's prescription, must be approved by the medical practitioners who have the right to prescribe, and sign or affix a special seal to be effective.
Seven, refresher doctors by the receiving department according to the actual situation of the competent professional work to determine and report to the medical department for approval, can be granted the corresponding temporary prescription right.
Eight, doctors should be based on the needs of medical treatment, prevention, health care, in accordance with the norms of diagnosis and treatment, indicating the indications, pharmacological effects, usage, dosage, contraindications, adverse reactions and precautions of drugs. The prescriptions of toxic drugs and radioactive drugs for medical use shall strictly abide by the provisions of relevant laws, regulations and rules.
Nine, according to the nature, function and task of the hospital, our hospital has formulated the hospital drug prescription set.
Ten, doctors should use the general name of the drug approved and published by the drug supervision and administration department, the name of the patented drug of the new active compound and the name of the compound preparation. Doctors should use the name approved by the provincial health administrative department and the drug supervision and administration department when prescribing hospital preparations. Doctors can use the customary names of drugs published by the Ministry of Health to make prescriptions.
XI。 The prescription is valid on the date of issuance. If it is necessary to extend the validity period under special circumstances, the prescriber shall indicate the validity period, but the longest validity period shall not exceed 3 days.
Twelve, the prescription is generally not more than 7 days; Emergency prescription shall generally not exceed 3 days; For some chronic diseases, senile diseases or special circumstances, the prescription dose may be appropriately extended, but the doctor should indicate the reasons. Prescription doses of toxic drugs and radioactive drugs for medical use should be strictly implemented in accordance with relevant state regulations.
Thirteen, doctors should be in accordance with the Ministry of health to develop the "guiding principles of clinical application of narcotic drugs and psychotropic drugs" to issue prescriptions for narcotic drugs and psychotropic drugs of category I. ..
Fourteen, outpatient (emergency) diagnosis of cancer pain patients and patients with moderate and severe chronic pain need long-term use of narcotic drugs and psychotropic drugs of category I, the first-time physician shall personally check the patients, write the corresponding medical records, sign the informed consent form to the medical department, and handle the relevant registration procedures. Copies of the following materials shall be kept in the medical records:
(a) a special diagnosis certificate issued by a doctor who has the right to prescribe anesthesia in our hospital;
(2) the patient's household registration book, ID card or other relevant valid identification documents;
(three) the identity certificate of the patient's agent.
Fifteen, except for patients with type I (emergency) cancer pain and patients with moderate and severe chronic pain who need to use narcotic drugs and psychotropic drugs for a long time, narcotic drug injections are only used in hospitals.
Sixteen, the outpatient (emergency) patients injected with narcotic drugs, each prescription for a common amount; Controlled-release and sustained-release preparations, each prescription shall not exceed 7 days; For other dosage forms, each prescription shall not exceed 3 days. Psychotropic drug injections of category I, each prescription is a common dose; Controlled-release and sustained-release preparations, each prescription shall not exceed 7 days; For other dosage forms, each prescription shall not exceed 3 days. When methylphenidate is used to treat ADHD in children, each prescription should not exceed the daily dose of 15. Psychotropic drugs of category II shall generally not exceed the dose of 7 days per prescription; For patients with chronic diseases or some special circumstances, the prescribed dose can be appropriately extended, and the doctor should explain the reasons.
Seventeen, for outpatient (emergency) diagnosed with cancer pain patients and patients with moderate and severe chronic pain, narcotic drugs, psychotropic drugs injection, each prescription shall not exceed 3 days; Controlled-release preparation, each prescription shall not exceed 15 daily dose; For other dosage forms, each prescription shall not exceed 7 days.
Eighteen, inpatient narcotic drugs and psychotropic drugs of category I prescription issued by the day, each prescription for 1 day dose.
Nineteen, for narcotic drugs that need special control, dihydroetorphine hydrochloride prescription is a common dose, and pethidine hydrochloride prescription is a common dose, which are restricted to use in our hospital.
Twenty, doctors for outpatient (emergency) diagnosis of cancer patients and patients with moderate and severe chronic pain, should require long-term use of narcotic drugs and psychotropic drugs of category I, and every 3 months for a follow-up or follow-up.
Twenty-one, doctors use computers to issue and transmit ordinary prescriptions, and should also print out paper prescriptions, the format of which is consistent with handwritten prescriptions; The printed paper prescription is valid after being signed or sealed. When pharmacists distribute drugs, they should check the printed paper prescriptions and distribute them to drugs after they are correct, and keep the printed paper prescriptions and computer-transmitted prescriptions for future reference.
Twenty-two, personnel who have obtained the qualifications for professional and technical positions in pharmacy can engage in prescription dispensing.
Twenty-three, the personnel who have obtained the title of pharmacist have obtained the qualification of prescription dispensing in our hospital. The pharmacist's signature or special signature pattern should be kept in our hospital for future reference.
Twenty-four, with pharmacists or above professional and technical post qualifications of personnel responsible for prescription review, evaluation, verification, drug distribution and safe drug use guidance; Pharmacists are engaged in prescription preparation.
Twenty-five, pharmacists should be filled with a doctor's prescription, not without a doctor's prescription.
Twenty-six, pharmacists should adjust prescription drugs according to the operating rules: carefully review the prescription, accurately allocate drugs, correctly write medicine bags or paste labels, and indicate the patient's name and drug name, usage, dosage and packaging; When delivering drugs to patients, the medication should be explained and guided according to the drug instructions or prescriptions, including the usage, dosage and precautions of each drug.
Twenty-seven, pharmacists should carefully check the prescription, words and postscript writing is clear and complete, and confirm the legitimacy of the prescription.
Twenty-eight, pharmacists should review the suitability of prescription drugs, including:
(1) For drugs that must undergo skin test, whether the prescription indicates the allergy test and result judgment;
(2) Consistency between prescription medication and clinical diagnosis;
(3) the correctness of dosage and usage;
(four) the rationality of the choice of dosage form and route of administration;
(five) whether there is a phenomenon of repeated administration;
(6) Whether there are potential clinical drug interactions and incompatibility;
(seven) other inappropriate drugs.
Twenty-nine, pharmacists in the prescription review, that there is improper use of drugs, it should inform the prescriber, asking him to confirm or re-prescribe. Pharmacists who find serious irrational drug use or drug use errors shall refuse to adjust, inform the prescriber in time, and record and report in accordance with relevant regulations.
30. What must pharmacists do when preparing prescriptions? Four checks and ten pairs? : Investigator, subject, name and age; Check drugs, drug names, dosage forms, specifications and quantities; Look up the contraindications of compatibility and discuss the characteristics, usage and dosage of drugs; Check the rationality of clinical diagnosis medication.
Thirty-one, pharmacists after completing the prescription adjustment, should sign or affix a special seal on the prescription.
Thirty-two, pharmacists should prepare the number of narcotic drugs and psychotropic drugs of category I every day.
Thirty-three, pharmacists may not adjust the prescriptions that are not standardized or whose legality cannot be judged.
Thirty-four, except narcotic drugs, psychotropic drugs, toxic drugs for medical use and pediatric prescriptions, outpatient personnel shall not be restricted from purchasing drugs from pharmaceutical retail enterprises by prescription.
Thirty-five, the hospital should strengthen the management of prescription, dispensing and storage.
Thirty-six, the establishment of prescription review system, fill in the prescription evaluation form, the implementation of prescription dynamic monitoring and extraordinary early warning, registration and notification of irrational prescriptions, timely intervention in irrational drug use.
Thirty-seven, give a warning to doctors who prescribe more than three times without justifiable reasons, and limit their prescription rights; After the prescription right is restricted, if there are still more than two consecutive abnormal prescriptions without justifiable reasons, the prescription right shall be revoked.
Thirty-eight, the doctor has one of the following circumstances, the prescription right shall be cancelled by the medical department:
(a) was ordered to suspend practice;
(two) during the training period, the examination failed to leave the post;
(3) The practice certificate has been cancelled or revoked;
(four) not in accordance with the provisions of the prescription, causing serious consequences;
(five) do not use drugs in accordance with the provisions, causing serious consequences;
(6) Seeking personal gain by prescription.
Thirty-nine, people who have not obtained the right to prescribe and doctors who have been canceled the right to prescribe may not prescribe. Doctors who have not obtained the qualification to prescribe narcotic drugs and psychotropic drugs of category I shall not prescribe narcotic drugs and psychotropic drugs of category I.
Forty, except for the needs of treatment, doctors may not prescribe narcotic drugs, psychotropic drugs, toxic drugs for medical use and radioactive drugs.
Forty-one, personnel who have not obtained the qualifications for pharmaceutical professional and technical positions shall not engage in prescription dispensing.
Forty-two, after the prescription is issued, it shall be properly kept by the pharmacy department. The storage period of common prescriptions, emergency prescriptions and pediatric prescriptions is 1 year, the storage period of toxic drugs for medical use and psychotropic drugs of category II is 2 years, and the storage period of narcotic drugs and psychotropic drugs of category I is 3 years. After the expiration of the prescription storage period, it can only be destroyed after being approved and registered by the competent dean.
Forty-three, the pharmacy department should according to the prescription of narcotic drugs and psychotropic drugs, the consumption of narcotic drugs and psychotropic drugs according to their varieties and specifications in a special volume, including the date of administration, the patient's name and the number of drugs. The special volume shall be kept for 3 years.
44. If Dr. Yamamoto is under any of the following circumstances, the hospital shall report to the Municipal Health Bureau for punishment in accordance with the provisions of Article 73 of the Regulations on Narcotic Drugs and Psychotropic Substances:
(1) Doctors who have not obtained the qualification for prescribing narcotic drugs and psychotropic drugs of category I prescribe narcotic drugs and psychotropic drugs of category I without authorization;
(2) Doctors who hold prescriptions for narcotic drugs and psychotropic drugs of category I fail to prescribe narcotic drugs and psychotropic drugs of category I in accordance with regulations, or use narcotic drugs and psychotropic drugs of category I in accordance with the Guiding Principles for Clinical Application of Narcotic Drugs and Psychotropic Drugs formulated by the Ministry of Health;
(three) the pharmacist fails to adjust the prescription of narcotic drugs and psychotropic drugs according to the regulations.
Forty-five, doctors in any of the following circumstances, in accordance with the provisions of Article 37 of the Law on Medical Practitioners, the hospital reported to the Municipal Health Bureau to give a warning or ordered to suspend the practice activities for more than six months and less than one year; If the circumstances are serious, his practice certificate shall be revoked:
(1) Prescribing drugs without obtaining the prescription right or after the prescription right is cancelled;
(two) failing to prescribe drugs in accordance with the provisions of these measures;
(three) in violation of other provisions of these measures.
Forty-six, pharmacists did not adjust the prescription drugs according to the regulations, and if the circumstances are serious, the hospital should report to the Municipal Health Bureau for correction, informed criticism, and give a warning; And the hospital will give disciplinary action.
Forty-seven, these rules shall come into force as of May 6, 2008 +0.