T/HENANPA 002-2022 The basic specifications for writing a medication record for hospitalized patients

Scope

Main technical content: It includes basic requirements and the content and requirements for writing the medication history of hospitalized patients. The basic requirements define the definition and overall requirements of the medication history of hospitalized patients. The content and requirements for writing the medication history of hospitalized patients include the admission pharmaceutical assessment of hospitalized patients, the first page of the medication history, pharmaceutical monitoring plans, pharmaceutical monitoring records, a summary of the medication history, and a summary of the treatment drugs during hospitalization. Among them, the admission pharmaceutical assessment of hospitalized patients evaluates the patient's admission status, medication compliance, self-reporting ability, and the level of pharmaceutical monitoring; the first page of the medication history includes the patient's basic information, chief complaint, current medical history, current medication treatment, past medical history, past medication treatment, personal medication and food allergy history, and adverse reaction management history, personal history, family history, and admission diagnosis; the pharmaceutical monitoring plan includes efficacy monitoring, safety monitoring, and compliance monitoring; the pharmaceutical monitoring records include the results of efficacy monitoring, safety monitoring, compliance monitoring, adjustments to the medication treatment plan, adjustments to the pharmaceutical monitoring plan, and medication guidance; the summary of the medication history includes the patient's admission date, discharge date, length of hospital stay, discharge diagnosis, summary of discharge medications, and discharge medication education; and the summary of the treatment drugs during hospitalization is a summary of all the medications used by the patient during hospitalization.

Development Information

Related Standards