Canaday B R, Yarborough P C
Division of Pharmacy Practice, School of Pharmacy, University of North Carolina, Chapel Hill.
Ann Pharmacother. 1994 Nov;28(11):1292-6. doi: 10.1177/106002809402801114.
To examine the need for a standardized, systematized approach to document patient pharmacotherapy, workable in all pharmacy practice settings, and to propose a model to meet the identified needs.
A MEDLINE search was conducted, in addition to an assessment of current practices and a review of known sources of pharmacotherapy/pharmaceutical care evaluation and documentation methodology.
Pharmacy lacks a universally accepted, standardized, systematized approach to document the evaluation of a patient's pharmacotherapy. An approach is presented that distills the concepts of pharmaceutical care into a manageable documentation format and provides a customization of the medical history and physical examination/subjective-objective-assessment-plan system to meet the unique needs of pharmacy. This approach provides a convenient format for notes for all pharmacists, applicable in any practice setting. It provides a starting point for decisions on what pharmacy wants and accepts as a standard to provide continuity of pharmaceutical care to patients, uniform communication with healthcare colleagues, appropriate instruction to students, data analysis to demonstrate the value of services, and needed guidance to software vendors, medical records departments, and third-party payers.
探讨是否需要一种标准化、系统化的方法来记录患者药物治疗情况，使其适用于所有药房实践环境，并提出一个模型以满足已确定的需求。
除了对当前实践进行评估以及对药物治疗/药学服务评估与记录方法的已知来源进行综述外，还进行了MEDLINE检索。
药房缺乏一种普遍接受的、标准化、系统化的方法来记录患者药物治疗评估情况。本文提出了一种方法，该方法将药学服务的概念提炼成一种易于管理的记录格式，并对病史和体格检查/主观-客观-评估-计划系统进行定制，以满足药房的独特需求。这种方法为所有药剂师提供了一种方便的记录格式，适用于任何实践环境。它为决定药房希望并接受何种标准以提供患者药物治疗的连续性、与医疗同事进行统一沟通、对学生进行适当指导、进行数据分析以证明服务价值以及为软件供应商、病历部门和第三方支付者提供所需指导提供了一个起点。
