Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, MD, USA.
Ann Emerg Med. 2013 Sep;62(3):205-11. doi: 10.1016/j.annemergmed.2013.04.014. Epub 2013 May 18.
Medication history is an essential part of patient assessment in emergency care. Patient-reported medication history can be incomplete. We study whether an electronic pharmacy-sourced prescription record can supplement the patient-reported history.
In a community hospital, we compared the patient-reported history obtained by triage nurses to a proprietary electronic pharmacy record in all emergency department (ED) patients during 3 months.
Of 9,426 triaged patients, 5,001 (53%) had at least 1 (mean 7.7) prescription medication in the full-year electronic pharmacy record. Counting only recent prescription medications (supply lasting to at least 7 days before the ED visit), 3,688 patients (39%) had at least 1 (mean 4.0) recent medication. After adjustment for possible false-positive results, recent electronic prescription medication record enriched the patient-reported history by 28% (adding 1.1 drugs per patient). However, only 60% of patients with any active prescription medications from either source had any recent prescription medications in their electronic pharmacy record.
The electronic pharmacy prescription record augments the manually collected history.
用药史是急救护理中评估患者的重要组成部分。患者自述的用药史可能不完整。我们研究电子药房处方记录是否可以补充患者自述的历史。
在一家社区医院,我们将分诊护士获得的患者自述病史与 3 个月内所有急诊部(ED)患者的专有电子药房记录进行比较。
在 9426 名分诊患者中,有 5001 名(53%)在整个电子药房记录中有至少 1 种(平均 7.7 种)处方药物。仅计算最近的处方药物(供应至少在 ED 就诊前 7 天),则有 3688 名患者(39%)有至少 1 种(平均 4.0 种)最近的药物。在调整可能的假阳性结果后,最近的电子处方药物记录使患者自述病史增加了 28%(每位患者增加 1.1 种药物)。然而,仅 60%的有任何活性处方药物的患者在其电子药房记录中有任何最近的处方药物。
电子药房处方记录补充了手动收集的病史。