It is the basis for doctors to make a list of drugs for patients, which can be used as a legal certificate of medical responsibility and also as a basis for drug statistics and settlement.
Attachment: Prescription standard 1. Prescription content 1. It includes the name of medical institution, charging category, patient's name, gender, age, outpatient or inpatient medical record number, department category or ward number and bed number, clinical diagnosis, date of issuance, etc. Items with special requirements can be added. The prescription of narcotic drugs and psychotropic drugs of category I shall also include the patient's identification number. Name and ID number of the agent. 2. Text: marked with Rp or R (abbreviation of Latin prescription "Please take it"), indicating the name, dosage form, specification, quantity, usage and dosage of the drug respectively. 3. P.S.: signature or special seal of the doctor, dosage, recheck, allocate and check, and signature or special seal of the pharmacist who issued the medicine. Second, the prescription color 1. Ordinary prescription printing paper is white. Two, emergency prescription printing paper is light yellow, marked with the words "emergency" in the upper right corner. Three, pediatric prescription printing paper is light green, marked with the words "pediatric" in the upper right corner. Four, narcotic drugs and psychotropic drugs of category I printing paper is light red, marked "marijuana and psychotropic drugs" in the upper right corner.
Prescription writing requirements: (1) The general situation and clinical diagnosis of the patient should be clearly and completely filled in, which is consistent with the medical record. (2) Each prescription is limited to one patient. (3) The handwriting is clear and shall not be altered. If it is necessary to modify, it should be signed on the modification book and indicate the date of modification. (4) The name of a drug shall be written in a standardized Chinese name; if there is no Chinese name, it may be written in a standardized English name; Yamatonokusushi, a medical institution or physician, shall not compile abbreviations or use codes by himself; The name, dosage, specifications, usage and dosage of drugs should be accurate and standardized. The usage of drugs can be written in standardized Chinese, English, Latin or abbreviations, but ambiguous words such as "according to doctor's advice" and "for personal use" are not allowed.
(5) The patient's age should be filled in, and if necessary, the date, month age and weight of the newborn and baby should be indicated. (6) Western medicine and Chinese patent medicine can be separated, and Chinese herbal pieces should be separated. (7) Western medicine and Chinese patent medicine should be prescribed separately, each medicine should be in a new line, and each prescription should not exceed five medicines. (8) Writing prescriptions for Chinese herbal pieces. The special requirements for dispensing and decocting drugs are indicated in the upper right of the drugs, and brackets are added, such as wrapping cloth, frying first, dropping later, etc. Where there are special requirements for the origin and processing of the decoction pieces, it shall be indicated before the name of the drug. (9) The usage and dosage of drugs shall conform to the conventional usage and dosage specified in the drug instructions. Special circumstances require excessive use, should indicate the reason, and once again indicate the clinical diagnosis. (10) Except in special circumstances, the blank space after the prescription is issued should be crossed to indicate that the prescription is finished. (12) The signature style and special signature of the prescriber shall be consistent with that of the hospital pharmacy.
Main contents of prescription
Name, sex, age, prescription date, number of hospitalizations or outpatient visits, address, expenses, clinical diagnosis, etc. Prescription head: RP-the abbreviation of verb Recipe, "take". Prescription text: drug name, specification, dosage and dosage unit. Preparation method: the preparation method of the medicine and the required dosage form. Administration method: one dose, times of administration and dosage unit.
Prescription writing rules 1. The prescription must be written in blue pen or ballpoint pen, and the handwriting should be clear and not altered. 2. The names of drugs and preparations should usually be written in the generic names of drugs (Chinese names or English names) approved by SFDA. 3. The dosage of drugs should be expressed in metric system, such as grams (g), milligrams (mg), micrograms (ug) and milliliters (ml). When the daily or disposable dosage of drugs exceeds the limit, doctors should re-sign the dosage to show their responsibility. Chinese and western medicine should be separated. 4 tablets, pills and capsules should indicate the content, taking tablets, pills and granules as the unit; Granules and granules take the minimum dose bag as the unit; Oral liquid, eye drops, injections, etc. Should be in the unit of rod or bottle, and should indicate the content. 5. The usage of drugs can be written in Chinese, English, Latin or abbreviations, but ambiguous sentences such as "following the doctor's advice" and "imitating drugs" cannot be used.
Prescription example
Name: Zhang * Gender: Male Age: 30 years old Outpatient/HospitalizationNo.: 150843 Address: * * University Department: Diagnosis; Cost: Date: March 20, 2007. Full name, specification, dosage, usage: one dose, daily administration times, administration route/postscript: including signature of doctor, signature of formulator, signature of auditor, etc.
The content of traditional Chinese medicine prescription is roughly similar to that of western medicine prescription. Generally, the patient's name, prescription, decoction (preparation), usage, contraindications and doctor's signature are included. Symptoms and diagnoses can be recorded in prescriptions, but they are generally kept separately at present. Traditional Chinese medicine prescriptions are generally written in Chinese. Attention should be paid to the additional terms of the names of traditional Chinese medicines in the prescriptions. The additional clauses of drug names refer to the clinical needs of doctors. Add one or two words before or after the proper name of the drug to indicate the doctor's medication requirements. Dispensers need to master these terms skillfully in order to accurately complete the prescription dispensing requirements and achieve the expected curative effect of doctors. The drug name has the following additional terms: 1. For those requiring the origin, such as Fritillaria cirrhosa, Fritillaria thunbergii, Radix Curcumae, Radix Curcumae, etc. Fritillaria thunbergii is good at nourishing yin and moistening lung, which is mostly used for deficiency syndrome, while Fritillaria thunbergii is good at clearing heat and cannot be replaced by each other. The nature and taste of drugs vary according to the geographical environment of the place of origin, so Chinese medicine pays attention to "authentic herbs". 2. Need the harvest season, such as tangerine peel, green tangerine peel, cotton fungus, etc. The quality of drugs is closely related to the harvest season. For example, Artemisia capillaris has the saying "Artemisia capillaris in March".
3. It is required to select and cut clean, such as Pinellia ternata and areca nut slices. The purpose of clean selection and cutting is to clean the medicine and process the medicine into pieces, segments, blocks and other "green pieces" with different shapes, so as to ensure the purity of the medicine and facilitate the frying of the effective components. 4. Require moxibustion: different processed products have different effects, such as Radix Rehmanniae as a heat-clearing and blood-cooling drug and Radix Rehmanniae as a blood-nourishing drug; Some can reduce toxicity, such as seed production; Some can improve the curative effect, and some can correct the taste. Therefore, it is impossible to replace each other when formulating. 5. There are requirements for physique, location and freshness, such as angelica head, ephedra root and fresh rehmannia root. Traditionally, it is believed that angelica head follows the sedan chair and angelica follows the blood; Ephedra root can sweat, ephedra stem can sweat, and Radix Rehmanniae is good at clearing away heat and promoting fluid production. Different parts and herbs have different effects, so we should pay attention to the prescription. In the prescriptions of traditional Chinese medicine, it is common to see the upper corner or lower corner of a drug name, and some labels are called "footnotes". Common footnotes have the following two functions. In the prescription of traditional Chinese medicine, it is common to see the upper corner or lower corner of a drug name. The added comments are called footnotes. Common footnotes have the following two functions: 1. If you need special frying methods, such as primary frying, secondary frying, color frying, melt frying, single frying, instant serving, blending, etc. When preparing, these drugs should be packaged separately and the usage should be indicated. The requirement is to prepare while doing, such as crushing, grinding and mashing.
Prescription text: drugs and dosage
Write the same line for each drug and dose; Latin abbreviations are often used in dosage forms; Drug name is the attribute of dosage unit, and the Latin ending is singular genus; The specification and quantity are written behind the drug name; The dosage unit is the object of the formula, with a receiver. The dosage unit is metric. The dosage unit "g" can be omitted; Other units must be indicated. There are two forms of dose expression: single dose method: single specification quantity * total number of required dosage forms; Total dose method: the required total dose is suitable for uncountable dosage forms.
Management method
Start with the abbreviation of Signa (sign, mark) S. or sig. Signa in the prescription means "please ask the pharmacy to indicate the usage on the medicine bottle so that the patient can know", and then write down the dosage, the number of times per day, the route and time of administration, etc. In turn, it is generally written on the next line of drugs and doses, which can be abbreviated in Latin or Chinese.
General rules and precautions of prescription writing
Special prescription pad with specified format, generally Chinese and foreign characters are not mixed; The handwriting is clear and shall not be altered at will; If there are any changes, the doctor should sign the changes. The names of drugs and preparations are generally written in Chinese or English, with the common names of drugs or with common names. The dosage of each drug shall not exceed the dosage of the drug instructions. Under special circumstances, if it is necessary to exceed the maximum amount, it should be signed to show that it is responsible for the safety of patients. The total dose should depend on the condition and the nature of the drug. The general dosage is three days, limited to seven days. Chronic diseases or special circumstances can be appropriately increased and should be signed.
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General rules and precautions of prescription writing
4. Special prescriptions (light red) should be used for class I narcotic drugs and psychotropic drugs, and light green prescriptions should be used for pediatrics (including pediatric emergency). 5. Those who need to take medicine immediately in an emergency should use an emergency prescription (yellow) or affix the word "urgent" or "cito!" in the upper left corner of the prescription. It should be written. The word (fast). 6. After the prescription is written, check it carefully; And make necessary explanations and explanations to patients.
Prescription text example
Rp。 Tetracycline Capsule 0.25 * 12 Usage: 0.25g each time, 4 times a day. Doctor signature RP. Hat. Tetracycline 0.25 * 12 sig. 0.25g once a day, signed by the doctor.
Prescription text example
When writing a drug name in a foreign language, the dosage form should be written in the top 3 of the drug name. ① aminophylline for injection 2.5%- 10.0 glucose for injection 50%-20.0sig.m.i.v.stat.lent! (slow) 2 tab. Aminophylline 0. 1 * 9 tab. luminali0.03 * 9 sig。 ③tab . glycyrhizae co . 18 # SIG . 2 # t . I