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《药学门诊及文书书写使用工作指引（参考）》制订与解析
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| 篇名： | 《药学门诊及文书书写使用工作指引（参考）》制订与解析 |
| TITLE： | Formulation and interpretation of the Guidelines for the Pharmacist-managed Clinics Service and Document Writing and Usage（Reference） |
| 摘要： | 药学门诊文书（简称“门诊药历”）书写是药学门诊的必要环节。门诊药历是体现药学门诊工作质量的重要载体。中国医院协会药事专业委员会受国家卫生健康委药政司的委托，牵头编制了《药学门诊及文书书写使用工作指引（参考）》（简称《指引》）。《指引》参照团体标准的编制方法，按照“资料梳理→框架建立→初稿撰写→意见征集→《指引》形成”的技术路线编制。《指引》对门诊药历管理的基本要求和书写的基本内容进行了规范，并提供了药学门诊药历通用模板和较具专科特色的妊娠期哺乳期药学门诊药历模板和咳喘药学门诊药历模板，为医疗机构书写门诊药历提供参考。本文介绍《指引》的制订过程，并解析《指引》的重点内容，有助于《指引》规范应用，进一步提升药学门诊工作质量。 |
| ABSTRACT： | The writing of pharmacist-managed clinics documents （hereinafter referred to as “outpatient medication record”） is a necessary part of pharmacist-managed clinics service. Outpatient medication record is an important carrier to reflect the quality of pharmacist-managed clinics service. The Chinese Hospital Association Pharmaceutical Specialized Committee was entrusted by the Pharmaceutical Administration Department of the National Health Commission to lead the formulation of the Guidelines for the Pharmacist-managed Clinics Service and Document Writing and Usage （Reference） （hereinafter referred to as Guidelines） according to the compilation method of group standards and the technical route of “documentation combing→framework establishment→draft writing→opinion collection→Guidelines formation”. The Guidelines standardizes the basic requirements of pharmacist-managed clinics record management and the basic content of record， and provides a general template and two specialized templates including pregnant and lactating pharmacist-managed clinics record template and cough and asthma pharmacist-managed clinics record template， which provides a reference for medical institutions to write pharmacist-managed clinics record. This paper introduces the formulation process of Guidelines and analyzes the key contents of Guidelines， which is helpful for the application practice of Guidelines and further improves the quality of pharmacist-managed clinics work. |
| 期刊： | 2025年第36卷第11期 |
| 作者： | 杨丽娟；李全志；王柯静；叶晓芬；王梓凝；闫雪莲；黄亮；李娟；甄健存 |
| AUTHORS： | YANG Lijuan， LI Quanzhi，WANG Kejing，YE Xiaofen，WANG Zining，YAN Xuelian，HUANG Liang，LI Juan，ZHEN Jiancun |
| 关键字： | 药学门诊；药学门诊文书；文书书写；工作指引 |
| KEYWORDS： | pharmacist-managed clinics； pharmacist- |
| 阅读数： | 4 次 |
| 本月下载数： | 0 次 |
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