今日药学

2019, v.29(03) 208-211

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门诊心血管疾病患者SOAP药历建立与应用
The Establishment and Application of SOAP Mode Medical Record for Cardiovascular Patients

钟运香;尹霖;卢锐辉;郑映璇;赖佩莹;苏剑华;何碧娟;
ZHONG Yunxiang;YIN Lin;LU Ruihui;ZHENG Yingxuan;LAI Peiying;SU Jianhua;HE Bijuan;Dept.of Pharmacy,The Fifth People's Hospital of Dongguan;Dongguan Municipal Public Hospital Management Center;Dept.of Cardiovascular Medicine,The Fifth People 's Hospital of Dongguan;Dept.of Information,The Fifth People 's Hospital of Dongguan;

摘要(Abstract):

目的探讨SOAP门诊药历在促进门诊患者安全合理用药及其在提高药学服务质量中的作用。方法选取近年在东莞市第五人民医院心内科多次住院的患者,采用SOAP模式建立门诊药历,结合其在药学监护中的实际应用情况,总结并分析其在促进门诊患者安全合理用药中的作用。结果通过对患者建立SOAP门诊药历,进行用药跟踪随访,药师能更好地将理论知识应用于临床,培养临床思维,能及时发现用药问题及潜在的不良反应,促进患者安全合理用药。结论 SOAP模式门诊药历能促进门诊患者安全合理用药,在提高门诊药师药学服务质量中有良好的应用前景。
OBJECTIVE To discuss the effect of outpatient medication record in SOAP mode in promoting outpatient's safety,rational drug use and improving pharmacy service. METHODS The SOAP mode outpatient medication record of some patients in the department of cardiology of the fifth people's hospital of Dongguan was established. Its significance in the enhancement of safe and reasonable drug usage was analyzed systematically. RESULTS The SOAP mode outpatient medication record was a very useful tool to guide pharmacists apply theory to clinic practice,cultivate their clinical thinking,found out potential medication problems or adverse drug reaction in time and enhanced the safe and reasonable usage of drugs. CONCLUSION Outpatient medication record in SOAP mode can promote outpatient's safety and rational drug use,and could be widely used in pharmacy service.

关键词(KeyWords): SOAP药历;门诊药历;药学服务;合理用药
SOAP record;outpatient medication record;pharmacy service;rational drug use

Abstract:

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基金项目(Foundation): 东莞市社会科技发展项目(2016年):SOAP模式的门诊药历建立及应用,项目编号:2016105101047

作者(Author): 钟运香;尹霖;卢锐辉;郑映璇;赖佩莹;苏剑华;何碧娟;
ZHONG Yunxiang;YIN Lin;LU Ruihui;ZHENG Yingxuan;LAI Peiying;SU Jianhua;HE Bijuan;Dept.of Pharmacy,The Fifth People's Hospital of Dongguan;Dongguan Municipal Public Hospital Management Center;Dept.of Cardiovascular Medicine,The Fifth People 's Hospital of Dongguan;Dept.of Information,The Fifth People 's Hospital of Dongguan;

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