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, the age should be over one year old, the date and month age should be written for newborns and babies, and the weight should be indicated if necessary;
2, traditional Chinese medicine decoction pieces, traditional Chinese medicine injection to a separate prescription;
3, western medicine, Chinese patent medicine prescription, each drug should be listed separately, each prescription shall not exceed 5 drugs;
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, Chinese herbal pieces, Chinese patent medicine prescription writing should comply with the "Chinese medicine prescription format and writing standard".
Suitability audit
(a) western medicine and Chinese patent medicine prescription, should review the following items:
1, the prescription medication is consistent with the diagnosis;
2, the provisions must do skin test drugs, whether to indicate the allergy test and the judgment of the results;
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. Whether there are contraindications for medication: whether there are contraindications for children, the elderly, pregnant women, lactating women and patients with organ dysfunction, whether the patient has a history of food and drug allergy, diagnostic contraindications, medical contraindications and gender contraindications;
8. Whether the selection, usage and dosage of solvents are appropriate, and whether the administration speed of intravenous infusion is appropriate;
9, whether there are other inappropriate 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. The names of decoction pieces and processed products are selected correctly, and 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. Whether special groups such as children, the elderly, pregnant women, lactating women and patients with organ dysfunction have contraindications;
5、? Whether there are other improper drug use.
Prescription structure
Prescription consists of three parts: preface, text and postscript.
1, Preface of prescription
Including the name of the medical institution, outpatient or inpatient case number, prescription number, department or ward and bed number, cost, patient's name, gender, age, clinical diagnosis, date of issuance, etc. , and you can add items required by your major.
2. Prescription text
The text of the prescription is marked with Rp or R, and the drug name, dosage form, specification, quantity, usage and dosage are listed respectively.
3, prescription postscript
The doctor's signature and/or special seal, the amount of drugs and the pharmaceutical professional and technical personnel who examine, allocate, check and distribute drugs.