Mason R N, Pugh C B, Boyer S B, Stiening K K
Department of Pharmacy, University of Virginia Health Sciences Center (UVaHSC), Charlottesville.
Am J Hosp Pharm. 1994 Sep 1;51(17):2131-8.
A computerized system for documenting interventions, developed by the pharmacy department at a 695-bed tertiary care university teaching hospital, is described. A computerized system was developed to better gain the needed details on pharmacists' recommendations, to capture a greater number of such recommendations, and to prepare for recent changes in standards of the Joint Commission on Accreditation of Healthcare Organizations. Only clinically important recommendations or those that involve cost savings are documented. Data can be entered and retrieved from any medical information system terminal in the hospital, and each entry becomes part of the patient's permanent record. A hard copy of all recommendations and a data file are generated daily. Analysis of the data has provided numerous opportunities for improving both patient care and the quality of pharmaceutical services. The system has been well received by pharmacists and has resulted in physician support of pharmacists' recommendations, as well as substantial cost savings. A convenient, easy-to-use computerized program for reporting interventions has helped a pharmacy department conduct departmental and institutional quality assurance activities and decrease costs.
本文描述了一所拥有695张床位的三级护理大学教学医院药学部开发的一个用于记录干预措施的计算机系统。开发该计算机系统是为了更好地获取药师建议的所需详细信息，记录更多此类建议，并为医疗机构评审联合委员会标准的近期变化做好准备。仅记录具有临床重要性的建议或涉及成本节约的建议。数据可从医院的任何医疗信息系统终端输入和检索，且每条记录都成为患者永久记录的一部分。每天都会生成所有建议的硬拷贝和一个数据文件。数据分析为改善患者护理和药学服务质量提供了众多机会。该系统受到了药师的好评，并获得了医生对药师建议的支持，还实现了大幅成本节约。一个方便易用的用于报告干预措施的计算机程序帮助药学部开展部门和机构质量保证活动并降低成本。
