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目的:了解北京地区16家二、三级医院处方规范情况,促进处方规范化管理。方法:收集北京地区16家医院2011年现用普通处方、麻醉药品处方、精神药品处方、儿童处方、急诊处方等各类纸质处方各1份。参照《处方管理办法》中处方标准及北京市卫生局标准处方格式,对处方颜色、前记、正文、后记、标注等规范性相关内容进行逐项对照,将对比结果进行统计分析。结果:本次调查共收集处方115张,其中普通处方56张、麻醉药品和一类精神药品处方16张、二类精神药品处方14张、儿童处方14张、急诊处方15张。不同项目规范比率分别为前记93.75%～100.00%,正文50.00%～100.00%,后记56.25%～93.75%。处方颜色、标注等一般格式规范比率为12.50%～93.75%。结论:处方格式及内容不规范情况普遍存在,亟待各医疗卫生机构按照相关规定印制处方,完善医院信息系统,严格执行《处方管理办法》规定的内容。
Objective: To understand the prescriptions of 16 second and third level hospitals in Beijing and to promote the standardized management of prescriptions. Methods: One copy of each paper prescription was collected from 16 hospitals in Beijing in 2011, including general prescriptions, narcotic prescriptions, prescriptions for psychotropic drugs, prescriptions for children and emergency prescriptions. With reference to prescription standards in the “prescription management approach” and the standard prescription format of Beijing Municipal Bureau of Health, the regulatory color of the prescription, the preamble, the text, postscripts and annotations are compared one by one, and the comparative results are statistically analyzed. Results: A total of 115 prescriptions were collected, including 56 general prescriptions, 16 prescriptions of narcotic drugs and psychoactive drugs, 14 prescriptions of psychotropic drugs of the second category, 14 prescriptions for children and 15 emergency prescriptions. Different items of the standard rates were 93.75% to 100.00% before the text, the text of 50.00% to 100.00%, Postscript 56.25% to 93.75%. Prescription color, labeling and other general format specification ratio of 12.50% ~ 93.75%. Conclusion: The prescription format and the content of the non-standard situation are ubiquitous. It is urgent for the medical and health institutions to print prescriptions in accordance with the relevant regulations, improve the hospital information system and strictly enforce the prescription prescribed in the Measures for the Administration of Prescriptions.