藥師臨床介入的紀錄系統

Classification System on Documenting Pharmacist Clinical Interventions

譚延輝(Yen-Huei Tarn) ； 李煥文(Huan-Wen Li)

《臺灣臨床藥學雜誌》 25卷1期 (2017/01) Pp. 1-12

https://doi.org/10.6168/FJCP.2017.2501.01

摘要

本藥師照顧病人的切入點，最重要是發現病人用藥是否存在藥物治療問題。若這問題與醫師開處方藥有關，必須與醫師溝通改善用藥；若與病人用藥行為有關，必須教育病人改變作法，然後追蹤這些臨床介入是否真正改變醫師開藥或病人用藥。藥師的臨床介入若沒記錄下來，則無法確知藥師照顧病人到底作了何事，也無法探討藥師參與照顧病人的意義與價值。若能有服務之編碼系統（AABBCC碼），則可將藥物治療問題性質作歸類、進行統計分析、作服務給付申報並整理出藥師的貢獻。本篇方法學文章描述藥事照護之理念，以及從理念所引導出來的專業行為與服務種類，並介紹藥師臨床介入的譚氏編碼與服務紀錄系統，再舉例說明此編碼之數據處理與呈現臨床成果的方法。

關鍵字

藥事照護 ； 編碼記錄系統 ； 藥物治療問題 ； 療效研究

並列摘要

The most important step of pharmacist intervention when conducting pharmaceutical care practice is to identify exist or potential drug therapy problems (DTP). If the DTP is related to physician prescribing, pharmacist should communicate with physician on how to resolve the problem; if it is patient-related, then proper use of the medication should be educated. Then, pharmacist should follow up to determine if the problem is really resolved. If the processes of problem identification (AA coding), conduct intervention (BB coding) and then follow up evaluation (CC coding) are not documented, no one will know what have pharmacist done, and there will be no way to investigate the meaning and value of the pharmaceutical care. Creating a classification system for pharmacist intervention not only can categorize the nature of the DTP, but also easy for statistical analysis, make a service claim, and shown the contributions of pharmacist to the patient care. This methodological article are aims to present the philosophy of pharmaceutical care and the pharmacist behaviors and services derived from the philosophy; present and demonstrate the Tarn's AABBCC coding system and how to document qualitatively; and give examples of showing the data and presenting the clinical outcomes of pharmacist clinical intervention.

並列關鍵字

Pharmaceutical Care ； Intervention Coding System ； Drug Therapy Problem ； Outcome Research