医学专题药历的类型及其书写E

1、药历的类型及其书写王 卓第二军医大学附属长海医院药学部中国人民解放军全军临床药学中心2021/7/20 星期二1病历：医院记录病人病史、诊断和处理方法的档案。药历：是由临床药师记录的关于发现、分析、观察和解决病人药物相关问题的技术档案。2021/7/20 星期二2药历及其作用是临床药师的必备文书资料。可以使临床药师和其他医务人员能够了解患者的药物相关信息。用于法律程序、教育、研究以及质量保证评价。是临床药师进行规范化药学服务的具体体现。2021/7/20 星期二3药历的存在形式医疗病历中的药历记录 药师单独记录的药历 电子药历 2021/7/20 星期二4二、药历的记录模式1以药物治疗为主的药

2、历。2以用药指导为目的的药历。3以问题为线索的药历。4以药物不良反应为线索的药历。5以治疗药物监测为目的的药历。2021/7/20 星期二5三、药历的记录形式叙述式表格式图表式手册式2021/7/20 星期二62021/7/20 星期二72021/7/20 星期二82021/7/20 星期二92021/7/20 星期二102021/7/20 星期二11中国临床药理学与治疗学，2000；5（2）：166-1682021/7/20 星期二12中国临床药理学与治疗学，2000；5（2）：166-1682021/7/20 星期二132021/7/20 星期二142021/7/20 星期二152021/

3、7/20 星期二162021/7/20 星期二17三、ASHP对药历记录的规定美国医疗机构药师协会（ASHP）2003年2月新修订的“ASHP Guidelines on Documenting Pharmaceutical Care in Patient Medical Records”明确指出：药师为保证用药的安全有效而进行的影响病人预后结果的专业活动必须书面记载于病人的病历 (PMR，patient medical record)。作为医学保健队伍整体的一员，临床药师的文书记录是病人连贯性监护的关键，也可以同时展示出药师服务的责任和价值。2021/7/20 星期二18基本要求必须以长期惯

4、用的形式记录在案。便于所有保健者密切联系和通力协作的形式，而不应该在交流和进行专业判断上制造壁垒。尽管紧急情况下电话和口头的交流必须在紧急情况处理之后尽快记录于病历。其他不太紧急和常规的建议最好也应尽快记录在案。2021/7/20 星期二19病历中药师记录的主要内容：病人入院前的主要用药史，包括药物过敏史及其具体表现；在病人药物治疗中药师向其他医务工作者提供的有关用药选择及处置方面的口头或书面会诊服务；医生口述的直接来源于药师的医嘱；就用药医嘱进行的说明解释；有关用药剂量、给药频率、药物剂型或给药途径方面的调整；病人已用药品（包括试验用药）；授权监测的已出现或潜在的药物相关问题；药物治疗监测所

5、见；所提供的药物相关的病人教育和相关咨询。2021/7/20 星期二20病人药物治疗方案的适当性（包括给药途径和方法）；病人药物治疗方案中的重复用药；已开药物医嘱的病人依从程度；已出现的或潜在的药物-药物、药物-食物、药物-实验室检查值及药物-疾病间的相互作用；临床及药动学实验数据相关的用药方案问题；已出现和潜在的药物中毒及药物不良事件；药物治疗相关的体征及临床症状；药物治疗监测所见2021/7/20 星期二21药师的文书记录应符合已建立以下标准：易懂、清楚、不含裁判性语言、完整、为病历所需要（相对于其他形式的交流）、有适当的标准模式可采用如SOAP（subjective, objective

6、, assessment, and plan）或TITRS(title, introduction, text, recommendation, and signature)，以及如何与药师联络（如电话或传呼机号码）。2021/7/20 星期二22保护病人隐私保证所进行的交流简明、准确还应考虑到当地的及联邦的相关指导原则、法规。应使用非裁判性的语言，要特别注意避免使用带有责备（如差错、失误、不幸、疏忽等）或不符合标准（如有害的、无效、不当、不宜、错误、不足、缺乏、问题及不满意）等暗示的文字。事实应记录得准确、清晰、客观，应能够反应整个医疗小组所建立的治疗目标。2021/7/20 星期二23正式

7、受邀的会诊可包括直接的建议和相应的意见。但是非正式受邀的会诊、临床印象、发现、意见或建议通常应记录得更为灵活（subtly），应使用非直接的建议，允许对方拒绝建议而不致承担责任。例如，若使用“可考虑”类的词汇，则可以有机会根据病情采纳或不采纳所提建议。2021/7/20 星期二24四、药历记录的格式与要求1病历式药历：一般资料既往用药史现用药史建议药物治疗计划药程录出院小结统计分析项目2021/7/20 星期二25一般资料内容基本与病历相同，例如姓名、性别、年龄、职业等一般项目，但作为药历，必须包括有正确的身高及体重，因这二项与今后药物建议方案、剂量选择紧密相关。2021/7/20 星期二26

8、既往用药史应在既往病史基础上加以扩充和延伸，应着重记载药物过敏史、药物不良事件以及既往病史所记述疾病的药物选择及疗效分析。2021/7/20 星期二27现用药史首先必须对现病史加以描述，在此基础上同步描述在现病史中各个阶段及各种症状及体征所选用药物治疗，以及药物治疗响应，包括疗效及不良事件。2021/7/20 星期二28建议药物治疗计划本内容为药历最重要组成部分，临床药师在作出建议前必须充分了解现诊断及临床上各项实验室检查结果，特别是与用药相关一些主要脏器功能状态，然后提出完整治疗计划，包括建议使用药物、剂量、给药途径，并需提出可能存在的药物相互作用，预见可能会发生不良反应，且尽可能需有定量监

9、测指标。2021/7/20 星期二29药程录与病历中的病程录相同步，且需与病程录中出现症状与体征描述相结合，逐日记载病员用药后疗效、不良事件及一些新出现症状与所用药物相关性，及时地更新药物治疗，确保在整个药疗过程中安全、有效、经济。2021/7/20 星期二30出院小结对整个药物治疗过程回顾性分析与总结。必须评述整个住院期药疗全貌，从中找出一些普遍规律，为病员出院后维持与巩固治疗提出建设性意见，且供药师在临床群体实践中积累经验。2021/7/20 星期二31统计分析项目以药物利用分析为目的的统计分析项目，可以对某病例某次住院期间的药物利用情况进行不同角度的分析统计，如：以疾病为中心进行统计分析

10、、以药物为中心进行统计分析、以费用为中心进行统计分析、以相类似作用药物为中心比较利用情况等。2021/7/20 星期二32SOAP模式S（Subjective）：患者的主诉病症和病史、过敏史、药物不良反应史、既往用药情况（包括药和家庭自用药物）、家族病史、个人习惯、是否吸毒。O（Objective）：对患者检查的客观记录 ，包括生命体征、生化指标、血药浓度、影像学检查结果、血和痰培养结果，检查和治疗费用等。这些检查将有助于明确诊断和治疗决策。2021/7/20 星期二33A（Assessment）：医师的临床诊断。P（Plan）：治疗方案，包括用法用量、服药时间、发药数量和用药指导，应对患者继

11、续观察的项目。药师根据这些信息可以进行药物治疗安全性和合理性的考察，评估药物药物、药物疾病间的相互作用，判断患者服药的依从性。2021/7/20 星期二34PH-MD-ROME模式药历P（Patient Intruduction，病人简介）简要介绍病人因出现何种情况、为何入院寻求医疗服务。记录日期、病人姓名、年龄（或出生年月）、民族、身高、体重、入院日期、性别、主诉（chief complaint）或病人现况描述。2021/7/20 星期二35H（Health Problem，健康问题）包括医疗诊断、精神病学诊断、病人主诉、异常实验室检查结果、异常的症状或体征、社会或经济状况、心理状况、生理缺

12、陷。有时还包括药师所进行的查体或问诊获得的病史。应注明病人自述的药物过敏史，对病人自己不详，而药师查知的过敏史应在确认后特别注明。在“健康问题”项下不讨论药物治疗。既往与目前的药物治疗情况将记录在“治疗药物”项下，如果必要时则在“药学诊断”项下进行讨论。2021/7/20 星期二36M（Medications，治疗药物）模块分为两部分：当前药物清单和已用药物清单。现用药品清单可以用来筛查药物相互作用、重复治疗、多重用药、是否过敏以及剂量是否适当。药师应不仅确定其过去用药方案中的剂量详情，更应考察该方案效果如何、是否发生不良事件以及为何后来停用了该方案等细节。2021/7/20 星期二37D (

13、Pharmaceutical diagnosis ，药学诊断)定义（Culbertson et al）：“用来鉴定病人特定的药物相关问题的、以问题为中心的认识过程。”叙述有关的药物相关问题及其分析、鉴别。每一个诊断都应提供足够的证据支持，并且应用药物治疗原则来解决该问题。药学诊断与药物治疗选择间的关系。要使用、调整和停用某种药物，都应该讨论其效益和风险。2021/7/20 星期二38药学诊断处方问题剂量不足剂量过大疗程过长疗程不足给药的具体时间表不当给药剂型或给药途径不当经济学不当医疗保险问题难辨认药物医嘱缺项或不详不易得药品2021/7/20 星期二39药物治疗评价相关问题未处置问题是否有必

14、要使用预防性用药、继续用药或长期维持用药治疗反应不佳适应证不明确或有疑问替代药物的选择重复治疗药动学评价2021/7/20 星期二40药物治疗的不良反应问题药物不良反应或不良事件潜在的禁忌证潜在的不良药物-饮食相互作用潜在的不良药物-药物相互作用潜在的不良药物-实验室检查相互作用2021/7/20 星期二41监测相关问题临床情况不完善临床检查数据不完善临床检查数据过多尚需进一步观察2021/7/20 星期二42病人相关因素依从性差用药过度用药精神依赖用药身体依赖（停药后可能出现撤药反应）药品储存不当病人教育问题病人教育不足特殊教育问题2021/7/20 星期二43R（Recommended O

15、rders，推荐医嘱）提出解决问题的办法。每条建议都应与上述药学诊断的编号对应。更深一步的分析讨论或综合等叙述性内容都应在上述“health problem”或“pharmaceutical diagnosis”项目下完善。药物治疗的建议应书写得尽可能简明，使用处方常用的缩略语，列出具体的药品、剂型、剂量、给药途径、剂量计划以及疗程等。2021/7/20 星期二44O（Desired Outcome，理想结果）设定特定的治疗目标或终点。应针对具体的监测指标提出哪些指标变化、哪些不便，提出治疗应达到的适当结果，并保证在此过程中病人不会遭受任何明显的药物不良反应。如果结果不能达到此预定目标，则必须

16、重新对其评估，并设定新的目标。2021/7/20 星期二45M（Monitoring，监测）监测所涉及的参数指标包括实验室检查、临床测定已经根据病人保健问题和药学诊断现状所反馈的情况预期的一些观察指标。每一种监测指标应列出其相应的监测时间、监测频率，必要时应注明特殊的监测者。2021/7/20 星期二46E（Patient Counseling and Education，病人咨询和教育）列出药师应提供给针对特定病人的重要的信息、建议、训练以及鼓励。如果出现“依从性不好”等情况时，则本项目下应包括对纠正该问题的具体指导。应具体记载对病人进行咨询教育的具体时间、方式、效果以及进行该工作的药师。2

17、021/7/20 星期二47五、药历举例SOAP扩展模式CHIEF COMPLAINTK.H. is a 52-year-old man who comes to the clinic today with complaints of shortness of breath and increased sputum production.HISTORY OF PRESENT ILLNESSHe reports that a rash began yesterday.He also complains of feeling depressed, lacking energy, waking up

18、 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. Although he has several medical problems, he has been doing well prior to this episode.2021/7/20 星期二48PAST MEDICAL

19、HISTORYChronic bronchitis secondary to smoking. Increasing SOB over last two years.Patient injured his right leg in a fall seven months ago. Deep vein thrombosis in the calf developed a week later.SOCIAL HISTORYK.H. has a stable and happy marriage; he has two sons in college, both doing well. K.H. c

20、ontinues to smoke 1 pack per day; he has 50 pack-year history. K.H. tried marijuana once with his son but did not like it.2021/7/20 星期二49MEDICATION HISTORYTheodur 600 mg bid for 2 yearsTerbutaline inhaler 4 puffs qid and pm for 2 yearsVibramycin 100 mg qd for bronchitis x 10 daysWarfarin 3 mg qd, st

21、arted 7 months agoAcetaminophen prn headacheALLERGIESNone known2021/7/20 星期二50PHYSICAL EXAMINATIONGEN: Middle aged man, in severe distressVS: BP 120/80, HR 100 reg, T 37.6, RR 32, Wt 80 kg, Ht 57HEENT: NormalCOR: Normal S1 and S2; no S3, S4 or murmursCHEST: Numerous rales, rhonchi, and wheezesABD: N

22、o organomegalyGU: WNLRECT: WNLEXT: NL DTRs, maculopapular rash on trunk and thighsNEURO: Oriented x 3, WNL2021/7/20 星期二51 RESULTS OF LABORATORY TESTSNa 140 Hct 55 Alb 4 K 4.0 Hgb 17.5 TBili .8 Cl 101 WBC 8.1Glu 95 Uric acid 7.4 HCO3 28 Plts 305kCa 8.8 BUN 37 Cr 1.2 P04 2.6AST 40 ALT 35 Mg 2.0 PT 25

23、(INR = 3)WBC differential: Neutrophils 4.8, bands 0, lymphs 3.0, monos .5, eos .12ABGs: pH 7.37, P02 55, PCO2 49PFTs: pre-bronchodilator FEV1 = 2000 mL (50% of FVC), post-bronchodilator FEV1 = 2600 mL (65% of FVC)Gram stain of sputum sample was unsuitable due to numerous squamous epithelial cellsUri

24、nalysis: WNLChest x-ray: Clear, no signs of pneumonia2021/7/20 星期二52PHARMACY-RELATED PROBLEM LIST1. Chronic bronchitis in an acute exacerbation2. Drug allergy3. Depression4. Deep Vein ThrombosisPROBLEM 1. CHRONIC BRONCHITIS EXACERBATIONS: K.H. complains of SOB and increased sputum production.O: K.H.

25、 has a decreased FEV1, rales, rhonchi, wheezes, an increased respiratory rate, pulse, Hct and Hgb, and arterial blood gases that show an increased PCO2 and a decreased oxygen. K.H. has a 50 pack-year smoking history.2021/7/20 星期二53A: K.H. has a symptomatic exacerbation of his chronic bronchitis that

26、 requires treatment. Smoking is the most likely etiology of the chronic bronchitis, while a viral upper respiratory tract infection is probably the cause of the acute exacerbation since K.H. shows no signs of systemic bacterial infection. He has a normal WBC, he is afebrile, and his chest x-ray is c

27、lear. The use of antibiotics in this situation is controversial, although recent evidence suggests a benefit. Pre-bronchodilator and post-bronchodilator FEV1 show reversible airway obstruction. The theophylline level is within the therapeutic range and there is no need to increase the dose.2021/7/20

28、 星期二54P: Give methylprednisolone 40-125 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.

29、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.s ability to use his inhaler correctl

30、y and correct any problems. Provide a spacer if necessary. Explain the likely side effects of theophylline, steroids, and ampicillin.K.H. should discontinue smoking; refer him to a smoking cessation clinic.2021/7/20 星期二55PROBLEM 2. DRUG ALLERGYS: K.H. complains of a rash that began yesterday, but do

31、es not complain of itching.O: K.H. has maculopapular rash on trunk and thighs, his eos is 1.2.A: K.H. has developed a rash due to the doxycycline started 9 days ago. The usual drug rash is maculopapular and commonly occurs after 7-10 days of therapy. Avoid antihistamines unless K.H. is itching, beca

32、use they are sedating and have anticholinergic effects.P: Discontinue Vibramycin. A veeno baths for a soothing effect may be needed. Label K.H. allergic to doxycycline.Monitor for resolution of the rash.Educate patient that he has an allergy to doxycycline and possibly other tetracyclines.2021/7/20

33、星期二56PROBLEM 3. DEPRESSIONS: 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 h

34、is 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 a

35、nd desipramine.2021/7/20 星期二57P: Begin fluoxetine 20 mg qd q am or at noon. Continue therapy for 6 months.Monitor changes in appetite, sleep pattern, interest in life, mood, quality of life, and suicidal thoughts. Physiologic signs and symptoms should improve in 1 week, while mood will take 2-4 week

36、s to respond. Also monitor for headaches, anxiety, insomnia, nausea, somnolence, dizziness or anticholinergic side effects.Advise patient to take fluoxetine in the morning or at noon to help prevent insomnia. Antacids may help with nausea. This drug may cause drowsiness or dizziness, so caution is a

37、dvised when driving or operating machinery. It will take several weeks for this drug to work or side effects to develop.2021/7/20 星期二58PROBLEM 4. DEEP VEIN THROMBOSISS: No complaintsO: The measurements of INR have shown wide swings over the last seven months. Presently the INR has stabilized around

38、3.0 for the last two months.A: Since the patient had only one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatmentP: Discontinue warfarin2021/7/20 星期二59PH-MD-ROME模式药历PATIENT INTRODUCTIONDate 2/24/97K.H. is a 52-year-old, 80 kg, 57” m

39、ale who comes to the clinic today with continued complaints of shortness of breath and increased sputum production.He reports that a rash began yesterday.He also complains of feeling depressed, lacking energy, waking up early in the morning and not being able to go back to sleep, a decreased appetit

40、e, and a general lack of interest in everything, including his job and his family for the last 6 weeks. Although he has several medical problems, he has been doing well prior to this episode.2021/7/20 星期二60HEALTH PROBLEMSChronic Bronchitis in an Acute ExacerbationSOB has been increasing over the las

41、t two years. The present respiratory rate is increased to 32. K.H. continues to smoke 1 pack per day. He has 50 pack-year history. Smoking is the most likely etiology of the chronic bronchitis. Numerous rales, rhonchi, and wheezes are heard on auscultation. Hct and Hgb are in the upper normal range

42、ruling out anemia as a cause for the SOB. Their elevation is probably secondary to hypoxia.Arterial blood gases indicate poor gas exchange, PCO2 is increased to 49 mm/Hg (normal 35-45), and PO2 is decreased to 55 mm/Hg (normal 80-100). An increased bicarbonate of 28 mEq/L (normal 20-26) shows compen

43、sation by the kidney resulting in a pH of 7.37, which is low-normal.WBC and differential are normal, temperature is normal, and chest x-ray is clear ruling out pneumonia. Gram stain of sputum sample was unsuitable due to numerous squamous epithelial cells A viral upper respiratory tract infection ma

44、y be the cause of the acute exacerbation.A pre-bronchodilator FEV1 = 2000 mL (50% of VC) indicates obstruction. However a post-bronchodilator FEV1 = 2600 mL (65% of VC) shows that this obstruction has a reversible component.2021/7/20 星期二61RashK.H. does not complain of itching. He has a maculopapular

45、 rash on trunk and thighs. His eosinophiles are in the normal range.DepressionThe five symptoms mentioned under patient introduction and their duration of over six weeks are consistent with a major depressive episode. However his breathing problem may be contributing to the mood disorder. The patien

46、t does not appear to be suicidal at this point.Deep Vein ThrombosisPatient injured his right leg in a fall seven months ago. Deep vein thrombosis in the calf developed a week later. The measurements of INR have shown wide swings over the last seven months. Presently the INR has stabilized around 3.0

47、 for the last two months.No known Allergies2021/7/20 星期二62MEDICATIONSPresent Medication ListTheodur 600 mg bid for 2 yearsTerbutaline inhaler 4 puffs qid and pm for 2 yearsVibramycin 100 mg qd for bronchitis x 10 daysWarfarin 3 mg qd, started seven months agoAcetaminophen prn HAPast Medication ListU

48、nknown2021/7/20 星期二63PHARMACEUTICAL DIAGNOSIS1. Suboptimal Response to BronchodilatorsD. G. has a symptomatic exacerbation of his chronic bronchitis that requires further treatment. The reversible airway obstruction would probably be amenable to additional bronchodilators. A theophylline level of 12

49、 mg/L is within the therapeutic range and pharmacokinetically consistent with his dosage. The use of antibiotics in this situation is controversial, although recent evidence suggests a benefit.2. Adverse Drug Reaction to DoxycyclineK.H. has developed a rash probably due to the doxycycline started 9

50、days ago. The usual drug rash is maculopapular and commonly occurs after 7-10 days of therapy. Avoid antihistamines unless K.H. is itching, because they are sedating and have anticholinergic effects.2021/7/20 星期二643. Untreated DepressionK.H. has had his current complaints for more than a month. Whil

51、e 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.4. Excessive Duration of Warfarin

52、ProphylaxisSince the patient has only had one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatment2021/7/20 星期二65RECOMMENDED ORDERS1. Methylprednisolone 45 mg iv stat and continue q 6 h for 72 hours.Aerosolized metaproterenol 4 puffs

53、 stat and 1 puff q 5 minutes until relief or side effects, then two puffs every 4 hours while awake.Continue oral theophylline, 600 mg bid.Oxygen 2 liters/minute via nasal prongs.Ampicillin 500 mg po qid for seven days.2. Discontinue Vibramycin.Label K.H. allergic to doxyclycline.Aveeno baths for a soothing effect as needed.3. Fluoxetine 20