2. Prescription standardization: check the contents of prescription preface, prescription text and prescription postscript, and whether the prescription preface, prescription text and prescription postscript are clear, complete and in line with the specifications;
3. Suitability of prescription
It is to judge the safety, rationality and economy of drug use and intervene in advance for drugs with safety and rationality problems.
Pharmacists are the first responsible person for prescription approval, and pharmacists should review the contents of prescriptions one by one. Medical institutions can assist pharmacists to carry out prescription audit through relevant information systems. The unreasonable prescriptions screened by the information system and the parts that cannot be audited by the information system shall be manually audited by pharmacists.
A pharmaceutical professional and technical personnel engaged in prescription review (hereinafter referred to as pharmacists) shall meet the following conditions:
(1) Having obtained the qualification of pharmacist with professional and technical positions in pharmacy or above.
(two) with more than 3 years of experience in prescription dispensing in outpatient and emergency departments or wards, and have received professional knowledge training in the corresponding positions of prescription audit and passed the examination.
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.
It is the pharmacist's duty to examine prescriptions. According to the requirements of the Ministry of Health, it is necessary to "check four 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. What is not signed by a doctor does not constitute a prescription, and the prescription is invalid, so the scope of trial only includes those signed by a doctor.
Secondly, there are three main contents in the review of doctors' prescriptions, one is the legality review, the other is the normative review, and the third is the suitability review.
Legitimacy audit
(1) Whether the prescriber has obtained the medical qualification and registered to practice in accordance with the Law on Medical Practitioners.
(two) when prescribing, whether the prescriber obtained the prescription right in the practice place according to the "Prescription Management Measures".
(three) whether the prescriptions of narcotic drugs, psychotropic drugs of category I, toxic drugs for medical use, radioactive drugs, antibacterial drugs and other drugs are prescribed by doctors with corresponding prescription rights.
Normative audit
(a) whether the prescription conforms to the prescribed standards and formats, whether the special signature signed or sealed by the prescription has been filed, and whether the electronic prescription has the electronic signature of the prescription.
(two) whether the preface, text and postscript of the prescription comply with the relevant provisions of the Measures for the Administration of Prescriptions, and whether the words used are correct, clear and complete.
(3) Whether the goods are standardized.
1. Age should be at least one year old. Newborns and babies should write the date and month age, and indicate the weight if necessary;
2 Chinese herbal pieces and injections should be prescribed separately;
3. Prescription of western medicine and Chinese patent medicine, with a separate line for each medicine and no more than 5 medicines for each prescription;
4. The name of the drug shall be the generic 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 drug, or the customary name of the drug published by the former Ministry of Health; Hospital preparations should use the name officially approved by the drug supervision and administration department;
5. The dosage, specifications, usage and dosage of the drug are accurate and clear, and conform to the provisions of the Prescription Management Measures. Do not use vague terms such as "following doctor's advice" and "for personal use";
6. The prescription quantity and prescription validity of commonly used drugs conform to the provisions of the Prescription Management Measures, and antibacterial drugs, narcotic drugs, psychotropic drugs, toxic drugs for medical use, radioactive drugs and precursor chemicals are used. Comply with relevant management regulations;
7. Prescription writing of Chinese herbal pieces and Chinese patent medicines shall conform to the Specification for Prescription Format and Writing of Chinese Medicine.
Suitability audit
(a) western medicine and Chinese patent medicine prescription, should review the following items:
1. Whether the prescribed medication is consistent with the diagnosis;
2. The drugs that require skin test should indicate whether the allergy test and the judgment of the results are indicated;
3 prescription dosage, usage is correct, the total amount of a single prescription is in accordance with the provisions;
4. Whether the dosage form and route of administration are appropriate;
5. Whether there is repeated administration and interaction, including whether there is repeated administration and clinical interaction between western medicine, Chinese patent medicine, Chinese patent medicine and western medicine, Chinese patent medicine and Chinese herbal pieces;
6. Is there any incompatibility?
7. Are there any contraindications: are there any contraindications for children, the elderly, pregnant women, lactating women and patients with organ dysfunction, and are there any contraindications for patients with food and drug allergies, diagnostic contraindications, medical contraindications and gender contraindications?
8. Whether the selection, usage and dosage of solvent are appropriate, and whether the administration speed of intravenous infusion is appropriate;
9. Whether there are other cases of improper medication.
(two) prescription of Chinese herbal pieces, should review the following items:
1. Whether the prescription of Chinese herbal pieces is consistent with the diagnosis of traditional Chinese medicine (disease name, syndrome type);
2. Whether the names of decoction pieces and processed products are selected correctly, and whether the frying method, usage and footnotes are complete and accurate;
3. Whether the thin pieces of poisonous hemp are in accordance with the regulations;
4 children, the elderly, pregnant and lactating women, organ dysfunction patients and other special groups whether there are contraindications;
5. Whether there are other cases of improper medication.
legal ground
Prescription management measures
Article 1 In order to standardize prescription management, improve prescription quality, promote rational drug use and ensure medical safety, these Measures are formulated in accordance with the Law on Medical Practitioners, the Drug Administration Law, the Regulations on the Administration of Medical Institutions, the Regulations on the Administration of Narcotic Drugs and Psychotropic Drugs and other relevant laws and regulations.
Article 2 Prescription as mentioned in these Measures 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, prepared and checked by pharmaceutical professional technicians (hereinafter referred to as pharmacists) who have obtained the qualifications for pharmaceutical professional and technical positions, and serve as medication vouchers for patients. Prescriptions include medical institution ward medication orders. These Measures are applicable to medical institutions and their personnel related to prescription, dispensing and storage.