药历的类型及其书写

1、 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。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 二、药历的记录模式 1以药物治疗为主的药历。 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。三、药历的记录形式 叙述式 表格式 图表式 手册式结核用药治疗中国临床药理学与治疗学，中国临床药理学与治疗学，2000；5（2）：）：166-168中国临床药理学与治疗学，中国临床药理学与治疗学，20

2、00；5（2）：）：166-168住院病人药历住院病人药历5月9日凯复定2.0g0.9nacl 100ml bid大扶康0.2g qd稳可信稳可信1g5gs 500 ml bid0.5g5gs速尿速尿 10mg iv bid亚星力确兴泰能5128393379姓名房某性别男年龄77病区/床号3b-*住院号/id号*66/*305现病史患者2003年11月23日，体检发现脑梗塞，在外院期间27日中午突发广泛脑梗塞，后一直处于昏迷状态。2004年3月27日来院就诊，给予高压氧治疗，当时查血常规：wbc15.4*109/l，给予先锋必、甲硝唑静滴7天，并给予甘油果糖，韦司太、氯酯醒治疗，4月4日患者出

3、现发热，体温波动于37.5-38.4，痰量明显增多，给予左旋氧氟沙星及庆大霉素静滴，10日加用凯复定、大扶康抗感染，痰培养示金黄色葡萄球菌基本诊断两肺炎；桥脑、延髓脑梗塞；心律失常；高血压病（极高危组）；右眼白内障；右下肢深静脉栓塞既往史59年行阑尾切除术，92年行鼻炎手术，否认其它外伤、手术史。预防接种史同社会。无药物过敏史，无输血史。tdm及相关检验记录及相关检验记录 日期4月28日4月29日4月30日5月1日5月3日5月5日5月7日5月8日血常规 wbc(109)9.77.03 gran82.269.5生化 尿素16.818.4 肌酐110107968673葡萄糖(m

4、mol/l)8.26.1 钾(mmol/l)3.44.3 钠(mmol/l)152143143139138 氯(mmol/l)1061021029798肝功总蛋白(g/l)6152白蛋白(g/l)3325alt（u/l）14048ast（u/l）5538r-gt（u/l）241107万古霉素监测万 古 谷 浓 度（ug/ml）46.0519.1114.22万 古 峰 浓 度（ug/ml）56.7319.49干预建议减量1半建议停药1次复查，以估算建议减量稳可信0.5g5gs 250ml bid凯复定大扶康稳可信0.5g5gs250ml qd速尿亚星2.25

5、g+0.9nacl 100ml bid力确兴0.2g+5gs 250ml qd改用0.9nacl100ml bid泰能0.5g q8h临床药师： 王卓 日期75.185.21血常规 wbc(109)10.949.78 gran75.771.8生化 尿素3.96.7 肌酐5576葡萄糖(mmol/l)6.35.3 钾(mmol/l)55 钠(mmol/l)1.41.38 氯(mmol/l)102101肝功总蛋白(g/l)白蛋白(g/l)alt（u/l）15ast（u/l）19r-gt（u/l）53万古霉素监测万 古 谷 浓 度（ug/ml）万 古 峰 浓 度（ug/ml）总

6、体评价患者入院前曾连续使用万古霉素（2g/d）和庆大霉素近1周，入院后肾功能即出现不良，后连续再次使用万古霉素后出现浓度蓄积，经过临床药师建议多次监测血药浓度，调整给药方案，后浓度控制较好，肾功能指标趋于正常。病人感染控制出院并转外院神经内科进行原发病治疗。 必须以长期惯用的形式记录在案。 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。保护病人隐私保护病人隐私保证所进行的交流简明、准确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

7、则、法规。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、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、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。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。立的治疗目标。 正式受邀的会诊可包括直接的建议和相应的意见。但正式受邀的会诊可包括直接的

8、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（通常应记录得更为灵活（subtly），应使用非直接的），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，若建议，允许对方拒绝建议而不致承担责任。例如，若使用使用“可考虑可考虑”类的词汇，则可以有机会根据病情采类的词汇，则可以有机会根据病情采纳或不采纳所提建议。纳或不采纳所提建议。 s（subjective）：患者的主诉病症和病史、过敏）：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（包括史、药物不良反应史、既往用药情况（包括药和家庭自用药

9、物）、家族病史、个人习惯、是否药和家庭自用药物）、家族病史、个人习惯、是否吸毒。吸毒。 o（objective）：对患者检查的客观记录）：对患者检查的客观记录 ，包括，包括生命体征、生化指标、血药浓度、影像学检查结果、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。有助于明确诊断和治疗决策。 a（assessment）：医师的临床诊断。）：医师的临床诊断。 p（plan）：治疗方案，包括用法用量、服药时间、）：治疗方案，包括用法用量、服药时间、发药数量和用药指导，应对患者继续观察的项

10、目。发药数量和用药指导，应对患者继续观察的项目。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。作用，判断患者服药的依从性。 p（patient intruduction，病人简介），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（族、身高、体重、入院日期、性别、主

11、诉（chief complaint）或病人现况描述。）或病人现况描述。 h（health problem，健康问题），健康问题） 包括医疗诊断、精神病学诊断、病人主诉、异常实验包括医疗诊断、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、室检查结果、异常的症状或体征、社会或经济状况、心理状况、生理缺陷。有时还包括药师所进行的查体心理状况、生理缺陷。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，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。别

12、注明。 在在“健康问题健康问题”项下不讨论药物治疗。既往与目前的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药物治疗情况将记录在“治疗药物治疗药物”项下，如果必要项下，如果必要时则在时则在“药学诊断药学诊断”项下进行讨论。项下进行讨论。 m m（medicationsmedications，治疗药物），治疗药物） 模块分为两部分：当前药物清单和已用药物清单。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。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

13、过去用药方案中的剂量详情，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。及为何后来停用了该方案等细节。 定义定义（culbertson et alculbertson et al）：）：“用来鉴定病人特定的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。药物相关问题的、以问题为中心的认识过程。”叙述叙述有关的药物相关问题及其分析、鉴别。每一个诊断都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应提供足够的证据支持，并且应用药物治疗

14、原则来解决该问题。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。停用某种药物，都应该讨论其效益和风险。药学诊断 r（recommended orders，推荐医嘱），推荐医嘱） 提出解决问题的办法。每条建议都应与上述药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。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更深一步的分析讨论或综合等叙述性内容都应在上述在上述“health problem”或或“pharmaceutical diagnosis”项目下完善。项目下完善。 药

15、物治疗的建议应书写得尽可能简明，使用处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。量、给药途径、剂量计划以及疗程等。 o（desired outcome，理想结果），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

16、目标，则必药物不良反应。如果结果不能达到此预定目标，则必须重新对其评估，并设定新的目标。须重新对其评估，并设定新的目标。 m（monitoring，监测），监测） 监测所涉及的参数指标包括实验室检查、临床测定已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。监测时间、监测频率，必要时应注明特殊的监测者。e（patient counseling and education

17、，病人咨询和教育），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、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。训练以及鼓励。 如果出现如果出现“依从性不好依从性不好”等情况时，则本项目下应包等情况时，则本项目下应包括对纠正该问题的具体指导。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、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。效果以及进行该工作的药师。五、药历举例 soap扩展模式 chief complaint k.h. is a 52-year-old man who comes to the

18、clinic today with complaints of shortness of breath and increased sputum production. history of present illness 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 appetite,

19、 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. past medical history chronic bronchitis secondary to smoking. increasing sob over last two years. patient inju

20、red his right leg in a fall seven months ago. deep vein thrombosis in the calf developed a week later. social history k.h. has a stable and happy marriage; he has two sons in college, both doing well. k.h. continues to smoke 1 pack per day; he has 50 pack-year history. k.h. tried marijuana once with

21、 his son but did not like it. medication history 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 7 months ago acetaminophen prn headache allergies none known physical examination gen: middle age

22、d man, in severe distress vs: bp 120/80, hr 100 reg, t 37.6, rr 32, wt 80 kg, ht 57 heent: normal cor: normal s1 and s2; 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, w

23、nl results of laboratory tests na 140 hct 55 alb 4 k 4.0 hgb 17.5 tbili .8 cl 101 wbc 8.1 glu 95 uric acid 7.4 hco3 28 plts 305k ca 8.8 bun 37 cr 1.2 p04 2.6 ast 40 alt 35 mg 2.0 pt 25 (inr = 3) wbc differential: neutrophils 4.8, bands 0, lymphs 3.0, monos .5, eos .12 abgs: ph 7.37, p02 55, pco2 49

24、pfts: 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 cells urinalysis: wnl chest x-ray: clear, no signs of pneumonia pharmacy-related problem list 1. chronic bronchitis in

25、an acute exacerbation 2. drug allergy 3. depression 4. deep vein thrombosis problem 1. chronic bronchitis exacerbation s: k.h. complains of sob and increased sputum production. o: k.h. has a decreased fev1, rales, rhonchi, wheezes, an increased respiratory rate, pulse, hct and hgb, and arterial bloo

26、d gases that show an increased pco2 and a decreased oxygen. k.h. has a 50 pack-year smoking history.a: k.h. has a symptomatic exacerbation of his chronic bronchitis that requires treatment. smoking is the most likely etiology of the chronic bronchitis, while a viral upper respiratory tract infection

27、 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 clear. the use of antibiotics in this situation is controversial, although recent evidence suggests a benefit. pre-bronchodilator an

28、d post-bronchodilator fev1 show reversible airway obstruction. the theophylline level is within the therapeutic range and there is no need to increase the dose.p: give methylprednisolone 40-125 mg iv stat and continue q6h for 72 hours. give aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minu

29、tes 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

30、 pressure, and tremor. the goal is to decrease morbidity and mortality associated with chronic bronchitis.assess k.h.s ability to use his inhaler correctly and correct any problems. provide a spacer if necessary. explain the likely side effects of theophylline, steroids, and ampicillin.k.h. should d

31、iscontinue smoking; refer him to a smoking cessation clinic.problem 2. drug allergys: k.h. complains of a rash that began yesterday, but does 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

32、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.p: discontinue vibramycin. a veeno baths for a soothing effect may be needed. label k.h. allergic to doxyc

33、ycline.monitor for resolution of the rash.educate patient that he has an allergy to doxycycline and possibly other tetracyclines.problem 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, a

34、nd 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,

35、when all costs are taken into account, is no more expensive to use than older tricyclic antidepressants such as imipramine and desipramine.p: 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,

36、and suicidal thoughts. physiologic signs and symptoms should improve in 1 week, while mood will take 2-4 weeks 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

37、prevent insomnia. antacids may help with nausea. this drug may cause drowsiness or dizziness, so caution is advised when driving or operating machinery. it will take several weeks for this drug to work or side effects to develop. problem 4. deep vein thrombosis s: no complaints o: the measurements o

38、f inr have shown wide swings over the last seven months. presently the inr has stabilized around 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 treatment p: discontinue warfa

39、rin patient introduction date 2/24/97 k.h. is a 52-year-old, 80 kg, 57” male 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

40、 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. health problems chronic bronchiti

41、s in an acute exacerbation sob has been increasing over the last 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 he

42、ard on auscultation. hct and hgb are in the upper normal range 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).

43、an increased bicarbonate of 28 meq/l (normal 20-26) shows compensation 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 squam

44、ous epithelial cells a viral upper respiratory tract infection may 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. rash k.h.

45、 does not complain of itching. he has a maculopapular rash on trunk and thighs. his eosinophiles are in the normal range. depression the five symptoms mentioned under patient introduction and their duration of over six weeks are consistent with a major depressive episode. however his breathing probl

46、em may be contributing to the mood disorder. the patient does not appear to be suicidal at this point. deep vein thrombosis patient 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

47、seven months. presently the inr has stabilized around 3.0 for the last two months. no known allergies 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 mo

48、nths ago acetaminophen prn ha past medication list unknown pharmaceutical diagnosis 1. suboptimal response to bronchodilators d. g. has a symptomatic exacerbation of his chronic bronchitis that requires further treatment. the reversible airway obstruction would probably be amenable to additional bro

49、nchodilators. a theophylline level of 12 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 doxycycline k.h. has developed a rash

50、probably 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, because they are sedating and have anticholinergic effects. 3. untreated depression k.h. has had his current complaint

51、s 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. 4. e

52、xcessive duration of warfarin prophylaxis since the patient has only had one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatment recommended orders 1. methylprednisolone 45 mg iv stat and continue q 6 h for 72 hours. aerosolized met

53、aproterenol 4 puffs 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