【正文】 共七十一頁。,中國(zhōnɡ ɡu243。,第十六頁，共七十一頁。)的規(guī)定,美國醫(yī)療機(jī)構(gòu)藥師協(xié)會(huì)〔ASHP〕2003年2月新修訂的“ASHP Guidelines on Documenting Pharmaceutical Care in Patient Medical Records〞明確指出：藥師為保證用藥的平安有效而進(jìn)行的影響病人預(yù)后結(jié)果的專業(yè)活動(dòng)必須書面(shūmi224。,根本(jīběn)要求,必須以長期慣用的形式記錄在案。ny236。o shī)記錄的主要內(nèi)容：,病人入院前的主要用藥史，包括藥物過敏史及其具體表現(xiàn)； 在病人藥物治療中藥師向其他醫(yī)務(wù)工作者提供的有關(guān)用藥選擇及處置方面的口頭或書面會(huì)診效勞； 醫(yī)生口述的直接來源于藥師的醫(yī)囑； 就用藥醫(yī)囑進(jìn)行的說明解釋； 有關(guān)用藥劑量、給藥頻率、藥物劑型或給藥途徑方面的調(diào)整； 病人已用藥品(y224。j249。,藥師的文書記錄(j236。,第二十二頁，共七十一頁。sh237。但是非正式受邀的會(huì)診、臨床印象(y236。,第二十四頁，共七十一頁。ngbi233。 wǎnɡ)用藥史,應(yīng)在既往病史根底上加以擴(kuò)充和延伸，應(yīng)著重記載藥物過敏史、藥物不良(b249。,現(xiàn)用藥(y242。,第二十八頁，共七十一頁。)建議使用藥物、劑量、給藥途徑，并需提出可能存在的藥物相互作用，預(yù)見可能會(huì)發(fā)生不良反響，且盡可能需有定量監(jiān)測(cè)指標(biāo)。n)病癥與所用藥物相關(guān)性，及時(shí)地更新藥物治療，確保在整個(gè)藥療過程中平安、有效、經(jīng)濟(jì)。必須評(píng)述整個(gè)住院期藥療全貌，從中找出一些(yīxiē)普遍規(guī)律，為病員出院后維持與穩(wěn)固治療提出建設(shè)性意見，且供藥師在臨床群體實(shí)踐中積累經(jīng)驗(yàn)。),以藥物利用分析為目的的統(tǒng)計(jì)分析工程，可以對(duì)某病例某次住院期間的藥物利用情況進(jìn)行不同角度的分析統(tǒng)計(jì)，如：以疾病(j237。,SOAP模式(m243。iyǎng)結(jié)果，檢查和治療費(fèi)用等。 P〔Plan〕：治療方案，包括用法(y242。,PHMDROME模式(m243。ng)、入院日期、性別、主訴〔chief complaint〕或病人現(xiàn)況描述。有時(shí)還包括藥師所進(jìn)行的查體或問診獲得的病史。,第三十六頁，共七十一頁。d236。〞表達(dá)有關(guān)的藥物相關(guān)問題及其分析(fēnxī)、鑒別。,第三十八頁，共七十一頁。och233。y224。n) 潛在的禁忌證 潛在的不良藥物飲食相互作用 潛在的不良藥物藥物相互作用 潛在的不良藥物實(shí)驗(yàn)室檢查相互作用,第四十一頁，共七十一頁。,病人相關(guān)因素 依從性差 用藥過度 用藥精神依賴 用藥身體(shēntǐ)依賴〔停藥后可能出現(xiàn)撤藥反響〕 藥品儲(chǔ)存不當(dāng) 病人教育問題 病人教育缺乏 特殊教育問題,第四十三頁，共七十一頁。 藥物治療的建議應(yīng)書寫得盡可能簡(jiǎn)明，使用處方常用的縮略語，列出具體的藥品、劑型、劑量、給藥途徑、劑量方案以及(yǐj237。應(yīng)針對(duì)具體的監(jiān)測(cè)指標(biāo)提出哪些指標(biāo)變化、哪些不便，提出治療應(yīng)到達(dá)的適當(dāng)結(jié)果，并保證(bǎozh232。,M〔Monitoring，監(jiān)測(cè)〕 監(jiān)測(cè)所涉及的參數(shù)指標(biāo)包括實(shí)驗(yàn)室檢查、臨床測(cè)定已經(jīng)根據(jù)病人保健問題(w232。,第四十六頁，共七十一頁。 如果出現(xiàn)“依從性不好〞等情況時(shí)，那么本工程下應(yīng)包括對(duì)糾正該問題的具體指導(dǎo)。),SOAP擴(kuò)展(ku242。 he has 50 packyear history. K.H. tried marijuana once with his son but did not like it.,第四十九頁，共七十一頁。 no S3, S4 or murmurs CHEST: Numerous rales, rhonchi, and wheezes ABD: No organomegaly GU: WNL RECT: WNL EXT: NL DTRs, maculopapular rash on trunk and thighs NEURO: Oriented x 3, WNL,第五十一頁，共七十一頁。,P: Give methylprednisolone 40125 mg iv stat and continue q6h for 72 hours. Give aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minutes until relief or appearance of side effects. Continue oral theophylline. Begin oxygen 2 liters/minute via nasal prongs. Begin ampicillin 500 mg po qid. Monitor SOB, sputum production, FEV1, ABGs, chest auscultation, theophylline level, nausea, vomiting, pulse, blood glucose, serum potassium, blood pressure, and tremor. The goal is to decrease morbidity and mortality associated with chronic bronchitis. Assess K.H.39。,PROBLEM 3. DEPRESSION S: K.H. complains of feeling depressed, lacking energy, waking up early in the morning and not being able to go back to sleep, a decreased appetite, and a general lack of interest in everything, including his job and his family for the last 6 weeks. O: None. A: K.H. has had his current complaints for more than a month. While he does not appear to be suicidal at this point, he needs treatment. Fluoxetine is as effective, has less side effects, and, when all costs are taken into account, is no more expensive to use than older tricyclic antidepressants such as imipramine and desipramine.,第五十七頁，共七十一頁。sh236。,MEDICATIONS Present Medication List Theodur 600 mg bid for 2 years Terbutaline inhaler 4 puffs qid and pm for 2 years Vibramycin 100 mg qd for bronchitis x 10 days Warfarin 3 mg qd, started seven months ago Acetaminophen prn HA Past Medication List Unknown,第六十三頁，共七十一頁。,DESIRED OUTCOMES 1. FEV1 greater than 2000 mL within two days Respiratory rate below 20, within two days ABG should all be within normal ranges within four days 2. Resolution of rash within 5 days 3. Patient’s appetite and sleep moderately improved within one week and mood moderately improved within 4 weeks, with no report of suicidal ideation or side effects listed in monitoring below.,第六十七頁，共七十一頁。s ability to use his inhaler correctly and correct any problems. Provide a spacer if necessary. Explain the likely side effects of bronchodilators: nausea, palpitations, anxiety or insomnia. K.H. should discontinue smoking。,內(nèi)容(n232。ng)及其書