I 团体标准 T/HENANNPA002-2002 住院药历书写基本规范 Basicspecification forwriting inpatient medical records 河南省药学会 发 布 全国团体标准信息平台 I 全国团体标准信息平台 I目次 目次........................................................................................................................................................I 前言......................................................................................................................................................II 引言....................................................................................................................................................III 住院药历书写基本规范............................................................................................................................4 1范围.......................................................................................................................................4 2规范性引用文件...................................................................................................................4 3术语和定义...........................................................................................................................4 3.1药品............................................................................................................................4 3.2临床药师......................................................................................................................4 3.3药学监护....................................................................................................................5 3.4药学查房....................................................................................................................5 3.5用药教育....................................................................................................................5 3.6药历............................................................................................................................5 3.7药学评估....................................................................................................................5 3.8药学监护分级............................................................................................................5 3.9药学监护计划............................................................................................................5 3.10药品不良反应..........................................................................................................5 3.11药品不良事件............................................................................................................5 4住院药历书写基本规范.......................................................................................................5 4.1基本要求......................................................................................................................5 4.2住院药历首页内容及书写要求.................................................................................6 4.3药学监护记录内容及书写要求.................................................................................7 4.4出院用药教育.............................................................................................................7 4.5药学监护小结.............................................................................................................8 附录A（规范性）住院药历模板.........................................................................................................9 附录B（规范性）药学监护分级标准...............................................................................................13 附录C（规范性）药学评估表..........................................................................................................15 附录D（资料性）治疗指数狭窄药物...............................................................................................16 附录E（资料性）药事管理指标计算公式.......................................................................................17 参考文献..................................................................................................................................................19 全国团体标准信息平台 II前言 本标准按照GB/T1.1-2020《标准化工作导则第1部分：标准化文件的结构和起草规则》 给出的规则体例格式起草。 本标准由河南省药学会、河南中医药大学第