医院22.用药医嘱及处方管理制度｛中英文版｝.docx

1 目的 Objective规范医院药物医嘱类型和完整的药物医嘱及处方要素To standardize types of medication orders, complete medication orders and key elements of prescription.2 人员资质 Qualifications2. 1在医院注册的执业医师经医务科审核后授予处方权，授权后方可开具处 方和医嘱Doctors registered in hospital are entitled to prescribe and given medication orders after approval from departinent of medical administration.2. 2有处方权的医师须在医务科和药剂科作签名留样及专用签章备案签名 留样不得任意改动，否则应重新登记留样备案Doctors who have the right of prescription shall leave samples of their signatures and seals in department of medical administration and pharmacy, which shal1 not be altered, otherwise new samples shall be registered.3 医嘱分类 Classification of medication orders3.1长期医嘱：有效时间在24小时以上，医生开具停止时间后失效，记录 在长期医嘱单上。

Long term order： valid for more than 24 hours, which shall cease to be effective at time specified by doctor and be recorded in long term order sheet.3.2临时医嘱：仅需执行一次的医嘱，“st”医嘱应立即执行，记录在临时 医嘱单上Temporary order： carry it out only once, "st" shall be carried out at once, record it in temporary order sheet.3.3医院不执行“PRN”医嘱PRN” is not carried out in our hospital.4 用药医嘱管理 Management of medication orders4. 1住院医生凭工号和密码登陆医院HIS系统，开具患者的住院医嘱，医嘱 内容、起始和停止日期及时间均要由医生电子签名Resident doctors shall log in hospital HIS system by code name and password to prescribe order of inpatient. Content, date and time of the order shal 1 have electronic signature of the doctor. 4.2所有药物的使用必须要有药物医嘱。

There must be medication orders for use of drugs.4.3多项同一日期和时间的医嘱，在起始行和终末行注明日期和时间，中间 栏目可以空白For several medication orders at the same time and on the same date, mark date and time at first line and last line, middle column can be blank.4.4医嘱内容应准确清晰，每条医嘱仅能包含一个内容Medication orders shall be precise and clear, each order contains one content.4.5每行内容左对齐Aligned left side4.6药名后写明剂型、单次给药量，用中文或规定的拉丁文缩写符号写明给 药次数、给药方法剂量要用法定剂量单位：国际单位(IU)、单位(U)； 重量以克(g)、毫克(mg)、微克(ug)、纳克(ng)为单位；容量以升(L)、皇升(ml)为单位；中药以克(g)为单位Write name of drug, dosage form, single dose, times and methods of administration in Chinese or specified Latin abbreviations. Use legal dose units： internal unit (IU) and unit (U)； gram (g), milligram (mg) , microgram (ug) and nanogram (ng) as units of weight； liter (L) and milliliter (ml) as units of capacity； gram (g) for Chinese medicine.4.7药品剂量与数量用阿拉伯数字书写，小数点前的“0”不得省略，整数 后必须写小数点和“0”。

Write dosage and quantity of medication in Arabic figure, “0" before decimal point cannot be omitted, write decimal point and “0” after integer.4.8液体剂型和注射剂以容量为单位时，须注明药物浓度(如0.2%替硝哇 注射液200ml )oWhen capacity is used as unit for liquid dosage and injection, write concentration of the drug (e. g. 0. 2% tinidazole injection 200ml).4.9中药医嘱应写明具体药物名称及剂量Write name and dosage of specific Traditional Chinese medicine in medication order.4.10 一组药物混合使用时，每种药物书写一行；用量按等于或低于包装量 的实际使用量书写；然后在一组药物后用大括号，表明下药加入上药 液When multi-drugs are used, write each drug in one line； write use volume as per actual use volume equal to or less than the packing volume； use a brace { } after a group of drugs to show adding following drugs into above liquid.4.11医嘱一经开出，不得涂改。

Given medication orders shall not be altered.4.12开具前核对患者姓名和住院号，并详细询问有无药物过敏史Before giving a medication order, verify name and admission number of the patient and inquire allergic history.4.13开具医嘱时，严格掌握药物说明书适应症与禁忌症，超说明书用药须 经医务科备案市核Medication orders shall be given strictly according to indications and contraindications specified in the instructions; drug use beyond the instructions shall be approved by department of medical administration.4. 14医嘱保存后经合理用药监测系统（即PASS系统）筛查，医生仔细阅读 系统提示的警示信息，必要时修改医嘱，再次经PASS系统筛查无误后 执行。

Keep the medication order for screening by PASS system, doctors shal1 read the warning information careful 1y suggested by the system, modify the order when necessary, then screen by PASS again.4.15医生开完医嘱后，护士认真核对，确认无误后发送至药剂科Nurse shall check the medication order seriously and then send it to pharmacy.4.16医务处组织对新员工关于开具用药医嘱方面的培训The department of medical administration shall organize training of new staff on medication orders.5 处方管理 Prescription management5.1处方为开具当日有效特殊情况下有效期不超过3天，须由医师注明 Prescription is valid for the date of issue only. Under special conditions, validation shall not exceed 3 days.5.2处方记载的患者一般项目（门诊ID号、姓名、性别、年龄等）应清晰、 完整，并与病历记载相一致。

Outpatient TD, name, sex and age on the prescription shal1 be clear and complete, identical with those in the case history.5.3医师开具处方时必须注明临床诊断，不得用不规范的字符或缩写代替 Doctors shall write clinical diagnosis in prescriptions, characters or abbreviations not up to the standard shall not be used.5.4每张处方只限于一名患者的用药Each prescription is limited to medications of one patient. 5.5医师开具处方前须详尽掌握患者自服药品清单，并记录在病历中Before write a prescription, the doctor must know the medications prepared and taken by the patient himself and write them in case history.5.6处方一律用规范的中文名称书写。

书写药品名称、剂量、规格、用法、 用量要准确规范Write drug name, dosage, specifications, method and volume of use accurately in standardized Chinese characters.5.7年龄必须写实足年龄，婴幼儿写。