Huntress J D, Possidente C J, Harry D J
Rochester General Hospital, Department of Pharmacy, NY 14621.
Am J Hosp Pharm. 1990 Dec;47(12):2711-5.
The development and implementation of a code that enables pharmacists to document their clinical interventions in the hospital's computerized patient records is described. To allow data to be entered in patient records from terminals throughout the hospital that are linked to the mainframe computer, a code was developed to summarize each pharmacist recommendation. The coded information is added to the computer entry for the specific drug requiring intervention. A computer program was developed inhouse for generating daily reports of the pharmacist interventions. During an initial 25-day study period, 300 interventions were documented; house staff physicians accepted the pharmacists' recommendations in 257 (85.7%) of these interventions. An additional 17 (6%) of the interventions resulted from physicians' requests for pharmacists' recommendations. In addition to review of all pharmacist clinical interventions, this system allows review of a specific target drug to determine compliance with institutional drug-use guidelines. Through use of the computer program developed at this hospital, information that documents pharmacists' clinical services can be entered directly into patients' records on the hospital's mainframe computer system and retrieved as useful reports.
本文描述了一种代码的开发与实施，该代码可使药剂师在医院的计算机化患者记录中记录其临床干预措施。为了能让数据从医院各处与主机相连的终端输入患者记录，开发了一种代码来总结每位药剂师的建议。编码信息会添加到需要干预的特定药物的计算机录入项中。内部开发了一个计算机程序，用于生成药剂师干预措施的每日报告。在最初的25天研究期内，记录了300次干预措施；住院医师接受了其中257次（85.7%）药剂师的建议。另外17次（6%）干预是医生要求药剂师提供建议导致的。除了审查所有药剂师的临床干预措施外，该系统还允许审查特定的目标药物，以确定是否符合机构用药指南。通过使用该医院开发的计算机程序，记录药剂师临床服务的信息可直接输入医院主机计算机系统中的患者记录，并作为有用的报告进行检索。
