CN116721734A - Prepositive prescription auditing method and system - Google Patents
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Abstract
The invention provides a pre-prescription auditing method and system, wherein the method comprises the following steps: inputting prescription information; checking according to the alarm mechanism, and judging the alarm level; judging whether the prescription passes the examination; issuing a prescription. The prepositive prescription auditing method takes the drug specifications, the drug guidelines, the expert consensus and the department drug characteristics as the multi-source auditing basis, so that the flexibility of drug use is improved; meanwhile, alarm strategies with different grades and categories are given, so that doctors and pharmacists can treat alarms in a classified mode, the auditing efficiency of the front-end auditing operation of the prescription is improved, the false alarm rate is effectively reduced, and the medical efficiency is improved.
Description
Technical Field
The invention belongs to the technical field of prescription auditing, and particularly relates to a prepositive prescription auditing method and system.
Background
The current pre-prescription auditing system takes a drug use instruction as a main auditing basis, and does not consider the medication practice requirements of different departments. If the clinical use requirement is met but the medicine is overdxplained, the existing prescription auditing system adopts forms of alarming, pharmacist doctor double-sign and the like to audit and pass, so that the problem of overhigh false alarm of the system is easily caused, alarming fatigue is caused, the real alarming problem is likely to be ignored, and the meaning of front prescription auditing is reduced.
Disclosure of Invention
In view of the above, the present invention aims to overcome the defects in the prior art, and provides a pre-prescription auditing method and system.
In order to achieve the above purpose, the technical scheme of the invention is realized as follows:
a pre-prescription auditing method, comprising the steps of:
s1, inputting prescription information;
s2, combining a medicine instruction database, a medicine use guide database, a consensus database and a department medication characteristic database, constructing a decision matrix for each medicine in the input prescription information, auditing the prescription information through an alarm mechanism according to the decision matrix,
judging whether an forbidden alarm is generated, if so, returning to the step S1, and re-inputting the modified prescription information; if no forbidden alarm is generated, judging whether a reminding type alarm is generated, if the reminding type alarm is not generated, directly entering a step S5, and if the reminding type alarm is generated, entering a step S3;
s3, dividing the alarm class of the reminding type alarm into a class I, a class II and a class III, and weakening the alarm severity in turn,
if the alarm level is I level, judging whether the prescription needs to be modified, if so, returning to the step S1, re-inputting the modified prescription information, and if not, supplementing opinion descriptions in the prescription, and entering into the step S4;
if the alarm level is II level, judging whether the prescription or the supplementary opinion illustration needs to be modified, if the prescription needs to be modified, returning to the step S1, re-inputting the modified prescription information, if the supplementary opinion illustration needs to be supplemented, supplementing the opinion illustration in the prescription, and entering the step S4, and if the prescription and the supplementary opinion illustration do not need to be modified, directly entering the step S4;
if the alarm level is level III, judging whether the suggestion description needs to be supplemented, if so, supplementing the suggestion description in the prescription, and entering a step S4, and if not, directly entering the step S4;
s4, checking and disposing of pharmacists, judging whether the prescription passes the checking, and if so, entering step S5; if the verification is not passed, returning to the step S1, re-inputting the modified prescription information, or judging whether the verification is passed according to the diagnosis condition, if the verification is passed according to the diagnosis condition, entering the step S5, and if the verification is not passed according to the diagnosis condition, returning to the step S1, and re-inputting the modified prescription information;
s5, issuing a prescription.
Further, the prescription information in step S1 includes patient information, indication, drug information, medication information, and doctor information, wherein the drug information includes a drug name, a dosage form, and a specification, and the medication information includes a medication route, each dosage, a medication unit, a medication frequency, a start time, and an end time.
Further, in step S2, the medicine instruction database comprises indication, medicine information and medication information,
the medication instruction database includes indications and medication information,
the consensus database includes indications and medication information,
the department medication characteristic database comprises indication and medication information.
Further, in step S2, the decision matrix includes the drug name and the sourceDecision factor，
Wherein according to the sourceHas a value of 1-4 and depends on the source +.>The value of 1 indicates that the decision is made according to the data item of the drug specification database according to the source +.>A value of 2 indicates that the decision is made according to the data item of the drug guidelines database, according to the source +.>A value of 3 indicates that the judgment is made according to the data item of the consensus database and the source is determinedA value of 4 indicates that judgment is carried out according to the data items of the department medication characteristic database;
decision factorIncluding the following that are included in the description,
the medicine information representing the medicine is based on the corresponding source +.>Whether the single daily maximum dose is exceeded, if so, +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>If the treatment course maximum dose is exceeded, then +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>Whether or not there is cross allergy, if there is cross allergy, & gt>The value is 1, and if cross allergy does not exist, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>If the contraindicated crowd is violated, the recipe is +.>The value is 1, and if the violation is not generated, the value is 0;
if there is no related medicine information in a certain database, its corresponding oneThe value is 0.
Further, in step S2, specific processes of the alarm mechanism for each medicine in the prescription are as follows:
calculation of Shan Richao dose violation，
，
Calculating the maximum dose overdose violation degree of the treatment course，
，
Calculating the allergic violation degree of each medicine，
，
Calculating the contraindicated violation degree of crowd，
，
When (when)Or->Or->Or->Generating forbidden alarms when the alarm is generated;
when (when)Or->Or->++/>+/>Generating a reminding type alarm, wherein the alarm grade is I grade;
when (when)+/>+/>+/>Generating a reminding type alarm, wherein the alarm grade is II grade;
when (when)+/>+/>+/>Generating a reminding type alarm, wherein the alarm grade is grade III;
when (when)、/>、/>、/>When the prescriptions are 0, no reminding type alarm is generated, and the prescriptions are directly issued.
Further, in steps S2-S4, the alarm information in each prescription is recorded and stored.
Further, in step S3, the alarm level of the prescription information is marked with different colors.
The invention also provides a pre-prescription auditing system based on the pre-prescription auditing method, which comprises the following steps:
the doctor prescription module comprises a prescription input unit and an alarm reminding unit, wherein the prescription input unit is used for inputting prescription information to form a patient prescription data item, the alarm reminding unit is used for receiving alarm reminding sent by the prescription auditing alarm module,
the prescription auditing database module comprises a drug instruction database, a consensus database and a department medication characteristic database, provides medication information under different standards required by the prescription auditing alarm module for auditing the prescription,
the prescription auditing and alarming module comprises a storage unit, an alarming decision unit and a data statistics unit, wherein the storage unit is used for storing prescription information, the alarming decision unit is used for constructing a decision matrix for each medicine according to the prescription information, auditing the prescription information through an alarming mechanism according to the decision matrix, giving an alarm to the auditing result, the data statistics unit is used for recording the alarming information in each prescription,
the pharmacist examination module comprises a prescription display unit and a pharmacist alarm disposal unit, wherein the prescription display unit is used for displaying the alarm grade of the prescription, marking the prescription with the alarm grade of I, II and III through different colors, and the pharmacist alarm disposal unit is used for carrying out corresponding examination work according to the alarm grade and the condition that a doctor modifies the prescription and supplements opinion explanation in the prescription, and after the examination of the prescription passes, the prescription is arranged below.
Compared with the prior art, the invention has the following advantages:
the prepositive prescription auditing method takes the drug specifications, the drug guidelines, the expert consensus and the department drug characteristics as the multi-source auditing basis, so that the flexibility of drug use is improved; meanwhile, alarm strategies with different grades and categories are given, so that doctors and pharmacists can treat alarms in a classified mode, the auditing efficiency of the front-end auditing operation of the prescription is improved, the false alarm rate is effectively reduced, and the medical efficiency is improved.
Drawings
The accompanying drawings, which are included to provide a further understanding of the invention and are incorporated in and constitute a part of this specification, illustrate embodiments of the invention and together with the description serve to explain the invention. In the drawings:
FIG. 1 is a flow chart of a pre-prescription auditing method according to an embodiment of the present invention;
FIG. 2 is a block diagram of a pre-prescription auditing system according to an embodiment of the present invention.
Detailed Description
It should be noted that, without conflict, the embodiments of the present invention and features of the embodiments may be combined with each other.
The invention will be described in detail below with reference to the drawings in connection with embodiments.
As shown in fig. 1, a pre-prescription auditing method includes the following steps:
s1, inputting prescription information;
s2, combining a medicine instruction database, a medicine use guide database, a consensus database and a department medication characteristic database, constructing a decision matrix for each medicine in the input prescription information, auditing the prescription information through an alarm mechanism according to the decision matrix,
judging whether an forbidden alarm is generated, if so, returning to the step S1, and re-inputting the modified prescription information; if no forbidden alarm is generated, judging whether a reminding type alarm is generated, if the reminding type alarm is not generated, directly entering a step S5, and if the reminding type alarm is generated, entering a step S3; forbidden alarms, preventing the prescription from being submitted, and the prescription must be modified for the prescription to be submitted; the reminding type alarm can be submitted after being modified or supplemented;
s3, dividing the alarm class of the reminding type alarm into a class I, a class II and a class III, and weakening the alarm severity in turn,
if the alarm level is I level, judging whether the prescription needs to be modified, if so, returning to the step S1, re-inputting the modified prescription information, and if not, supplementing opinion descriptions in the prescription, and entering into the step S4;
if the alarm level is II level, judging whether the prescription or the supplementary opinion illustration needs to be modified, if the prescription needs to be modified, returning to the step S1, re-inputting the modified prescription information, if the supplementary opinion illustration needs to be supplemented, supplementing the opinion illustration in the prescription, and entering the step S4, and if the prescription and the supplementary opinion illustration do not need to be modified, directly entering the step S4;
if the alarm level is level III, judging whether the suggestion description needs to be supplemented, if so, supplementing the suggestion description in the prescription, and entering a step S4, and if not, directly entering the step S4;
s4, checking and disposing of pharmacists, judging whether the prescription passes the checking, and if so, entering step S5; if the verification is not passed, returning to the step S1, re-inputting the modified prescription information, or judging whether the verification is passed according to the diagnosis condition, if the verification is passed according to the diagnosis condition, entering the step S5, and if the verification is not passed according to the diagnosis condition, returning to the step S1, and re-inputting the modified prescription information;
s5, issuing a prescription.
The prescription information in step S1 is input according to the illness state of a patient and comprises patient information, indication, medicine information, medication information and doctor information, wherein the medicine information comprises a medicine name, a dosage form and a specification, and the medication information comprises a medication route, each dosage, a medication unit, a medication frequency, a start time and an end time. The prescription data table of prescription information is shown in table 1, wherein the table entry id_i in the indication is a numerical number given for different diagnoses, which is a value ranging from 0 to 99999, and each code corresponds to a unique indication; the table item ID_dr in the doctor information is a personal identification symbol of the doctor, and the identification symbol ID_dr of each doctor in the hospital is unique; the table item id_de in the doctor information is an identification symbol of the department to which the doctor belongs, and the identification symbol id_dr of each department in the hospital is unique.
Table 1 prescription data entry
In step S2, the drug instruction database includes indications, drug information, medication information, and data table items thereof are shown in table 2,
table 2 data entry in drug instruction database
The drug use guideline database comprises indication and medication information, the data table items of which are shown in table 3,
table 3 pharmaceutical use guidelines database data entries
The consensus database stores information which is expert consensus data information including indications and medication information, the data table items of which are shown in table 4,
table 4 consensus database data item
The department medication characteristic database comprises indication and medication information, and the data table items are shown in table 5.
Table 5 department medication profile database
In step S2, each data table of the decision matrix is shown in Table 6, including the name of the drug and the basis of the sourceDecision factor->，
Wherein according to the sourceHas a value of 1-4 and depends on the source +.>The value of 1 indicates that the decision is made according to the data item of the drug specification database according to the source +.>A value of 2 indicates that the decision is made according to the data item of the drug guidelines database, according to the source +.>A value of 3 indicates that the judgment is made according to the data item of the consensus database and the source is determinedA value of 4 indicates that judgment is carried out according to the data items of the department medication characteristic database;
decision factorIncluding the following that are included in the description,
the medicine information representing the medicine is based on the corresponding source +.>Whether the single daily maximum dose is exceeded, if so, +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>If the treatment course maximum dose is exceeded, then +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>Whether or not there is cross allergy, if there is cross allergy, & gt>The value is 1, and if cross allergy does not exist, the value is 0;
the medication information of the medicine is represented by the corresponding source
If the contraindicated crowd is violated, if the contraindicated crowd is violated
The value is 1, and if the violation is not generated, the value is 0;
if there is no related medicine information in a certain database, its corresponding oneThe value is 0.
In the step S2, specific processes of the alarm mechanism aiming at various medicines in the prescription are as follows:
calculation of Shan Richao dose violation，
，
Calculating the maximum dose overdose violation degree of the treatment course，
，
Calculating the allergic violation degree of each medicine，
，
Calculating the contraindicated violation degree of crowd，
，
When (when)Or->Or->Or->Generating forbidden alarms when the alarm is generated;
when (when)Or->Or->++/>+/>Generating a reminding type alarm, wherein the alarm grade is I grade;
when (when)+/>+/>+/>Generating a reminding type alarm, wherein the alarm grade is II grade;
when (when)+/>+/>+/>Generating a reminding type alarm, wherein the alarm grade is grade III;
when (when)、/>、/>、/>When the prescriptions are 0, no reminding type alarm is generated, and the prescriptions are directly issued. In this embodiment, for level I alerts, the doctor must choose to modify prescription information or supplement the opinion presentation before submitting it; for class II alarms, the physician maySelecting to modify prescription information, supplement opinion descriptions and submit the prescription information or directly submit the prescription information; for class III alerts, the physician may choose to submit the supplemental opinion presentation later, or directly.
Table 6 alarm decision module decision matrix
In the steps S2-S4, the alarm information in each prescription is recorded and stored, so that the subsequent analysis and statistics of the data are convenient.
In step S3, the alarm level of the prescription information is marked with different colors, if the alarm level is level I, the prescription information is marked with red, if the alarm level is level II, the prescription information is marked with yellow, and if the alarm level is level III, the prescription information is marked with blue.
As shown in fig. 2, the present invention further provides a pre-prescription auditing system based on the pre-prescription auditing method, including:
the doctor prescription module comprises a prescription input unit and an alarm reminding unit, wherein the prescription input unit is used for inputting prescription information to form a patient prescription data item, the alarm reminding unit is used for receiving alarm reminding sent by the prescription auditing alarm module,
the prescription auditing database module comprises a drug instruction database, a consensus database and a department medication characteristic database, provides medication information under different standards required by the prescription auditing alarm module for auditing the prescription,
the prescription auditing and alarming module comprises a storage unit, an alarming decision unit and a data statistics unit, wherein the storage unit is used for storing prescription information, the alarming decision unit is used for constructing a decision matrix for each medicine according to the prescription information, auditing the prescription information through an alarming mechanism according to the decision matrix, giving an alarm to the auditing result, the data statistics unit is used for recording the alarming information in each prescription,
the pharmacist examination module comprises a prescription display unit and a pharmacist alarm disposal unit, wherein the prescription display unit is used for displaying the alarm grade of the prescription, marking the prescription with the alarm grade of I, II and III through different colors, and the pharmacist alarm disposal unit is used for carrying out corresponding examination work according to the alarm grade and the condition that a doctor modifies the prescription and supplements opinion explanation in the prescription, and after the examination of the prescription passes, the prescription is arranged below. In this embodiment, for prescriptions that are divergent, the pharmacist may coordinate with the doctor and pass the prescription, or the doctor may modify the prescription. In this embodiment, when the alarm reminding unit in the doctor prescription module receives the alarm level reminding sent by the prescription verification alarm module, the alarm reminding unit displays the color of the corresponding alarm level, and the doctor determines the required operation according to the color.
The operation of the above method and system is illustrated below:
when the system is applied to a certain hospital, part of the information in the relevant database information in the system is shown in tables 7 to 10.
TABLE 7 drug Specification database part data
Table 8 drug guidelines database portion data
Table 9 consensus database portion data
Table 10 department medication characteristics database portion data
Example 1
Table 11 prescription 1 data
For this recipe, the following calculations were performed:
，
，
，
，
+/>+/>+/>，
therefore, the system directly passes the prescription 1 without warning information and does not need doctors and pharmacists to process.
Example 2
Table 12 prescription 2 data
For this prescription, since drug D is a contraindicated for pregnant women, it is calculated as follows:
，
resulting in triggering a forbidden alert requiring modification of prescription 2 and resubmitting the prescription after selecting another drug.
Example 3
Table 13 prescription 3 data
For this recipe, the following is calculated:
，
，
，
，
+/>+/>+/>，
triggering a class II alert, filling in the supplementary information description: the dosage is the conventional dosage of the medicine for the indication in the department of the family. The pharmacist reviews the alarm and issues the prescription through the review.
The foregoing description of the preferred embodiments of the invention is not intended to be limiting, but rather is intended to cover all modifications, equivalents, alternatives, and improvements that fall within the spirit and scope of the invention.
Claims (8)
1. A pre-prescription auditing method, comprising the steps of:
s1, inputting prescription information;
s2, combining a medicine instruction database, a medicine use guide database, a consensus database and a department medication characteristic database, constructing a decision matrix for each medicine in the input prescription information, auditing the prescription information through an alarm mechanism according to the decision matrix,
judging whether an forbidden alarm is generated, if so, returning to the step S1, and re-inputting the modified prescription information; if no forbidden alarm is generated, judging whether a reminding type alarm is generated, if the reminding type alarm is not generated, directly entering a step S5, and if the reminding type alarm is generated, entering a step S3;
s3, dividing the alarm class of the reminding type alarm into a class I, a class II and a class III, and weakening the alarm severity in turn,
if the alarm level is I level, judging whether the prescription needs to be modified, if so, returning to the step S1, re-inputting the modified prescription information, and if not, supplementing opinion descriptions in the prescription, and entering into the step S4;
if the alarm level is II level, judging whether the prescription or the supplementary opinion illustration needs to be modified, if the prescription needs to be modified, returning to the step S1, re-inputting the modified prescription information, if the supplementary opinion illustration needs to be supplemented, supplementing the opinion illustration in the prescription, and entering the step S4, and if the prescription and the supplementary opinion illustration do not need to be modified, directly entering the step S4;
if the alarm level is level III, judging whether the suggestion description needs to be supplemented, if so, supplementing the suggestion description in the prescription, and entering a step S4, and if not, directly entering the step S4;
s4, checking and disposing of pharmacists, judging whether the prescription passes the checking, and if so, entering step S5; if the verification is not passed, returning to the step S1, re-inputting the modified prescription information, or judging whether the verification is passed according to the diagnosis condition, if the verification is passed according to the diagnosis condition, entering the step S5, and if the verification is not passed according to the diagnosis condition, returning to the step S1, and re-inputting the modified prescription information;
s5, issuing a prescription.
2. The pre-prescription auditing method of claim 1, wherein: the prescription information in step S1 includes patient information, indication, drug information, medication information, and doctor information, wherein the drug information includes a drug name, a dosage form, and a specification, and the medication information includes a medication route, each dosage, a medication unit, a medication frequency, a start time, and an end time.
3. The pre-prescription auditing method of claim 1, wherein: in step S2, the drug instruction database includes indications, drug information, medication information,
the medication instruction database includes indications and medication information,
the consensus database includes indications and medication information,
the department medication characteristic database comprises indication and medication information.
4. The pre-prescription auditing method of claim 1, wherein: in step S2, the decision matrix includes the name of the drug and the basis of the sourceDecision factor->，
Wherein according to the sourceHas a value of 1-4 and depends on the source +.>The value of 1 indicates that the decision is made according to the data item of the drug specification database according to the source +.>The value of 2 indicates that the decision is made according to the data item of the drug administration guidance database according to the source +.>A value of 3 indicates that the decision is made on the basis of the data item of the consensus database, according to the source ∈>A value of 4 indicates that judgment is carried out according to the data items of the department medication characteristic database;
decision factorIncluding the following that are included in the description,
the medicine information representing the medicine is based on the corresponding source +.>Whether the single daily maximum dose is exceeded, if so, +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>If the treatment course maximum dose is exceeded, then +.>The value is 1, if the value does not exceed the value, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>Whether or not there is cross allergy, if there is cross allergy, & gt>The value is 1, and if cross allergy does not exist, the value is 0;
the medicine information representing the medicine is based on the corresponding source +.>If the contraindicated crowd is violated, the recipe is +.>The value is 1, and if the violation is not generated, the value is 0;
if there is no related medicine information in a certain database, its corresponding oneThe value is 0.
5. The method for pre-prescription auditing according to claim 4, wherein in step S2, specific procedures of the alarm mechanism for each medicine in the prescription are:
calculation of Shan Richao dose violation，
，
Calculating the maximum dose overdose violation degree of the treatment course，
，
Calculating the allergic violation degree of each medicine，
，
Calculating the contraindicated violation degree of crowd，
，
When (when)Or->Or->Or->Generating forbidden alarms when the alarm is generated;
when (when)Or->Or->+/>++/>Generating a reminding type alarm, wherein the alarm grade is I grade;
when (when)+/>+/>+/>Generating a reminding type alarm, wherein the alarm grade is II grade;
when (when)+/>+/>+/>When in use, a reminding type alarm is generated and is reportedThe alarm grade is grade III;
when (when)、/>、/>、/>When the prescriptions are 0, no reminding type alarm is generated, and the prescriptions are directly issued.
6. The pre-prescription auditing method of claim 1, wherein: in the steps S2-S4, the alarm information in each prescription is recorded and stored.
7. The pre-prescription auditing method of claim 1, wherein: in step S3, the alarm levels of the prescription information are marked with different colors.
8. A pre-prescription auditing system for implementing the pre-prescription auditing method of any of claims 1-7, comprising:
the doctor prescription module comprises a prescription input unit and an alarm reminding unit, wherein the prescription input unit is used for inputting prescription information to form a patient prescription data item, the alarm reminding unit is used for receiving alarm reminding sent by the prescription auditing alarm module,
the prescription auditing database module comprises a drug instruction database, a consensus database and a department medication characteristic database, provides medication information under different standards required by the prescription auditing alarm module for auditing the prescription,
the prescription auditing and alarming module comprises a storage unit, an alarming decision unit and a data statistics unit, wherein the storage unit is used for storing prescription information, the alarming decision unit is used for constructing a decision matrix for each medicine according to the prescription information, auditing the prescription information through an alarming mechanism according to the decision matrix, giving an alarm to the auditing result, the data statistics unit is used for recording the alarming information in each prescription,
the pharmacist examination module comprises a prescription display unit and a pharmacist alarm disposal unit, wherein the prescription display unit is used for displaying the alarm grade of the prescription, marking the prescription with the alarm grade of I, II and III through different colors, and the pharmacist alarm disposal unit is used for carrying out corresponding examination work according to the alarm grade and the condition that a doctor modifies the prescription and supplements opinion explanation in the prescription, and after the examination of the prescription passes, the prescription is arranged below.
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