11

出院衛教準備服務出院衛教準備服務

日 期日 期 : : 97.04.20 (97.04.20 ( 日日 ) 13:00-13:30) 13:00-13:30

報告者報告者 : : 吳秉峰 藥師吳秉峰 藥師

中國醫藥大學附設醫院藥劑部中國醫藥大學附設醫院藥劑部

22

OutlineOutline A Pharmacist’s RoleA Pharmacist’s Role Pharmaceutical CarePharmaceutical Care S O A PS O A P Patient AssessmentPatient Assessment Patient EducationPatient Education Case ReportCase Report

33

A Pharmacist’s RoleA Pharmacist’s Role

44

Pharmacist’s Role TodayPharmacist’s Role Today In the pastIn the past: Take Rx order, dispensing, : Take Rx order, dispensing,

distributing, patient counselling.distributing, patient counselling. TodayToday, the role of pharmacists is becoming , the role of pharmacists is becoming

increasinglyincreasingly patient-orientedpatient-oriented. Therefore,. Therefore, is not is not uncommon for patients to have pharmacists uncommon for patients to have pharmacists solely providing solely providing patient assessmentpatient assessment..

55

Future Pharmacist’s RoleFuture Pharmacist’s Role FutureFuture: provide some level of primary care: provide some level of primary care

Administer Vaccinations.Administer Vaccinations. Order lab tests.Order lab tests. Engage in disease management activities, Engage in disease management activities,

including make diagnoses of certain clinical including make diagnoses of certain clinical conditions.conditions.

Change dosage of Rx, change Rx order, Change dosage of Rx, change Rx order, prescribing.prescribing.

Dispensing OTC products.Dispensing OTC products.

66

The evolving role of the pharmacistThe evolving role of the pharmacist

Move from Move from counting & dispensing counting & dispensing medicationsmedications, more toward focus on , more toward focus on treatment treatment & knowledge of the product& knowledge of the product..

More More patient interactionpatient interaction and and patient patient counsellingcounselling..

Play key role in Play key role in patient safetypatient safety.. A greater involvement in assisting patients A greater involvement in assisting patients

with managing their disease states.with managing their disease states. A greater A greater information sourceinformation source for the patient. for the patient.

77

College of King

88

Pharmaceutical CarePharmaceutical Care

99

Pharmaceutical CarePharmaceutical Care DefinitionDefinition: : the responsible provision of drug therapy for the responsible provision of drug therapy for

the purpose of achieving definite outcomes that improve the purpose of achieving definite outcomes that improve a patient’s quality of life.a patient’s quality of life. ((Hepler CD, Strand LM.1990)1990)

Cure of disease.Cure of disease.

Elimination or reduction of a patient’s symptom.Elimination or reduction of a patient’s symptom.

Arresting or slowing of a disease process.Arresting or slowing of a disease process.

Preventing a disease or symptom.Preventing a disease or symptom.

1010

1111

1212

1313

1414

Sequence and Components for Presenting InformationSequence and Components for Presenting Information

GenGen: General Patient Information. : General Patient Information. CCCC: Chief Complaint.: Chief Complaint. HPIHPI: History of Present Illness.: History of Present Illness. PMHPMH: Past Medical History.: Past Medical History. FHFH: Family History.: Family History. SHSH: Social History.: Social History. Allergy History.Allergy History. MedHxMedHx: Medication History (: Medication History (Prescription and Prescription and

OTCOTC ).). ROSROS: Review of System.: Review of System.

1515

Sequence and Components for Presenting InformationSequence and Components for Presenting Information

PEPE: Physical Exam: Physical Exam LabLab: Laboratory and diagnostic test results: Laboratory and diagnostic test results Admission DiagnosisAdmission Diagnosis Hospital CourseHospital Course ComplicationComplication Discharge DiagnosisDischarge Diagnosis Recommendations & MedicationsRecommendations & Medications S O A PS O A P

1616Cambridge

1717

S O A PS O A P

1818

S O A P

S： CC HPICC HPI PMH FHPMH FH SH AllergySH Allergy MedHx ROSMedHx ROS

P ： Recommendations &Recommendations & MedicationsMedications

CC: Chief Complaint.HPI: History of Present Illness.PMH: Past Medical History.FH: Family History.SH: Social History.MedHx: Medication History.ROS: Review of System.PE ： Physical ExamLab ： Laboratory and diagnostic test results

O： PE Labs OperationOperation

A： Admission DiagnosisAdmission Diagnosis Hospital CourseHospital Course ComplicationComplication Discharge DiagnosisDischarge Diagnosis Drugs ListDrugs List

1919

Patient AssessmentPatient Assessment

2020

What needs to be consideredWhat needs to be considered

Patient information.Patient information.

Disease information.Disease information.

Drug information.Drug information.

2121

Disease AssessmentDisease Assessment Problem Identification.Problem Identification. Signs and Symptoms.Signs and Symptoms. Treatment Goal.Treatment Goal. Desired Outcome.Desired Outcome. Supportive Data.Supportive Data. Therapeutic Alternatives.Therapeutic Alternatives. Optimal Plan.Optimal Plan. Outcome Evaluation.Outcome Evaluation.

2222

Drug AssessmentDrug Assessment Drug use without indication.Drug use without indication. Untreated indication.Untreated indication. Improper drug selection.Improper drug selection. Subtherapeutic dosage.Subtherapeutic dosage. Overdosage.Overdosage. ADR.ADR. Drug interaction.Drug interaction. Failure to receive medication.Failure to receive medication.

2323

Problem List Problem List

List of drug’s problems.List of drug’s problems.

Use Evidence-based information to assist Use Evidence-based information to assist healthcare team to identify the problem(s).healthcare team to identify the problem(s).

2424

PlanPlan Action Plan for treating this patient.Action Plan for treating this patient. Including interventions.Including interventions. Patient education.Patient education. Follow-up plan.Follow-up plan. Follow-up evaluation.Follow-up evaluation.

2525

College of Queen

2626

Patient EducationPatient Education

2727

Name of DrugName of Drug Administration, dosage, frequency, duration of usageAdministration, dosage, frequency, duration of usage Special instruction.Special instruction. Storage.Storage. Self-monitoring.Self-monitoring. Chronic usage, refill information.Chronic usage, refill information. Contraindication, caution.Contraindication, caution. ADR, side effect.ADR, side effect. Drug-Drug, Drug-Disease, Drug-Food interaction.Drug-Drug, Drug-Disease, Drug-Food interaction. What to do if you forget one dose.What to do if you forget one dose.

2828

Case ReportCase Report

2929

General information(Gen)General information(Gen) 姓名 : 鄭 XX

病歷號 : 00147XXXX500147XXXX5

住院期間 :96/11/22~96/11/2896/11/22~96/11/28

年齡 : 78歲 身高 : 157cm

性別 : 女 職業 : 家庭主婦

體重 : 64kg 過敏史 : NKDA

3030

Chief Complaint (CC):Chief Complaint (CC): ----chest tightness and general weakness for 2 week.chest tightness and general weakness for 2 week.

History of Present Illness (HPI) :History of Present Illness (HPI) : ----78 y/o female with history of HTN, heart disease, 78 y/o female with history of HTN, heart disease,

hyperuricemia, CKD suffered from chest tightness hyperuricemia, CKD suffered from chest tightness and general weakness for 2 week, intermittent chest and general weakness for 2 week, intermittent chest pain, no radiation pain, no cold sweating, no pain, no radiation pain, no cold sweating, no dyspnea, orthopnea(-), no leg edema, heart burn(+), dyspnea, orthopnea(-), no leg edema, heart burn(+), hoarseness(+), few cough for 2 days-> r/o GERD,no hoarseness(+), few cough for 2 days-> r/o GERD,no stool passage for 3 days, no abdominal pain.stool passage for 3 days, no abdominal pain.

3131

Past Medical HistoryPast Medical History 過去六個月就診錄過去六個月就診錄 ::

日期日期 科別科別 診斷診斷

96/10/1696/10/16 腎臟科腎臟科 背痛、慢性腎衰竭、痛風背痛、慢性腎衰竭、痛風

96/10/2396/10/23 腎臟內科腎臟內科 背痛、慢性腎衰竭、痛風、背痛、慢性腎衰竭、痛風、自發性高血壓自發性高血壓

96/11/2096/11/20 心臟科心臟科 自發性高血壓、焦慮狀態、自發性高血壓、焦慮狀態、痛風、高尿酸血症、失眠、痛風、高尿酸血症、失眠、眩暈眩暈

96/11/2296/11/22 急診內科急診內科 眩暈、自發性高血壓眩暈、自發性高血壓

3232

Physical ExaminationPhysical Examination General appearanceGeneral appearance:: --acute illness, nourished.--acute illness, nourished. Mental stateMental state:: --alert and well-orientated.--alert and well-orientated. Vital signVital sign:: ----T/P/R: 36.2 / 70 / 18, BP: 135 / 67 mmHgT/P/R: 36.2 / 70 / 18, BP: 135 / 67 mmHg Perfusion and oxygenationPerfusion and oxygenation:: --warm extremities without cyanosis.--warm extremities without cyanosis. HEENTHEENT:: -- gross normal; pink conjunctiva, anicteric sclera.-- gross normal; pink conjunctiva, anicteric sclera.

3333

Physical ExaminationPhysical Examination NeckNeck:: --supple; no palpable lymphadenopathy or thyroid nodules.--supple; no palpable lymphadenopathy or thyroid nodules. ChestChest:: --symmetric expansion; Breath sound: clear.--symmetric expansion; Breath sound: clear. HeartHeart:: --regular heart beats with systolic murmur.--regular heart beats with systolic murmur. AbdomenAbdomen:: --no tenderness or muscle guarding, normoactive bowel --no tenderness or muscle guarding, normoactive bowel

sounds.sounds. ExtremitiesExtremities:: --free movable, but muscle weakness.--free movable, but muscle weakness.

3434

Laboratory and diagnostic test resultsLaboratory and diagnostic test results

3535

Lab.DataLab.Data UnitUnit normalnormal 10/1610/16 10/2310/23 11/2211/22

SGPTSGPT

(ALT)(ALT)

IU/LIU/L 0-400-40 6969

SGOTSGOT

(AST)(AST)

IU/LIU/L 5-345-34 6161

CPKCPK IU/LIU/L 女女 ::

26-14026-140

887887

B.U.NB.U.N mg/dlmg/dl 5-265-26 33 2121

CreatinineCreatinine mg/dlmg/dl 0.5-1.30.5-1.3 1.6 1.6 1.51.5

Uric acidUric acid mg/dlmg/dl 女女 ::

1.9-6.51.9-6.5

13.5 13.5 10.110.1

CCR ml/min 88-12888-128 45.9

Phosphorus mg/dl 2.7-4.5 5.0

MCHMCH pgpg 27-3127-31 31.231.2

3636

Lab.DataLab.Data UnitUnit normalnormal 10/1610/16 10/2310/23 11/2211/22

MonocytesMonocytes %% 3.4-93.4-9 18.118.1

Nitrite Negative +

Leukocyte Negative +

Epith. Cell 1/HPF 0~5 8/HPF

WBC 0~5 8

Triglyceride Mg/dl 35-165 214

96 / 10 / 16 Renal Sonography: --Bilateral small kidneys, C/W chronic renal disease, bilateral renal

cysts. 96 / 11 / 20 T1-201 STRESS / REST MYOCARDIAL PERFUSION SPECT --suggesting stress-induced myocardial ischemia, suggesting

stress-induced LV dysfunction.

3737

Admission DiagnosisAdmission Diagnosis Chest pain, suspect GERD, CAD. Chest pain, suspect GERD, CAD. HCVD.HCVD. CKD, stage III. CKD, stage III. Gout.Gout. Constipation. Constipation. Insomnia.Insomnia. GERDGERD: Gastroesophageal Reflux Disease.: Gastroesophageal Reflux Disease.

CADCAD: Coronary Artery Disease.: Coronary Artery Disease. HCVDHCVD: Hypertension Heart Disease: Hypertension Heart Disease CKDCKD: Chronic Kidney Disease.: Chronic Kidney Disease.

3838

Hospital CourseHospital Course Due to EKG in ER showed normal, and no increase in Due to EKG in ER showed normal, and no increase in

troponin I lever, ACS was no likely.troponin I lever, ACS was no likely. After admission, she was arranged PES which After admission, she was arranged PES which

showed gastric ulcer, GERD and CLO(+).showed gastric ulcer, GERD and CLO(+). Triple therapy was prescribed.Triple therapy was prescribed. Medicine as CV OPD, laxative agents, sedative Medicine as CV OPD, laxative agents, sedative

agents, and analgesic agents were prescribed too.agents, and analgesic agents were prescribed too.

EKGEKG: electrocardiograph: electrocardiograph ACSACS: Acute Coronary Syndroms: Acute Coronary Syndroms PESPES: Pendoscope: Pendoscope CLO(+)CLO(+): Endoscopic biopsy for rapid urase : Endoscopic biopsy for rapid urase

assay. assay.

3939

Drugs ListDrugs List

4040

Item / Dose Frequency 11/22(住院 )

11/23 11/24 11/24 11/26 11/27 11/28(出院 )

Allopurinol 100 mg/T (1TB) QD.PO

Colchicine 0.5 mg/T (1TB) QD.PO

MELOXICAM 15 mg/Tab (1TB) QD.PO STAT

Acetaminophen 500 mg/T (1TB) QID.PO STAT STAT

STAT

Aspirin 100 mg/Cap (1Cap) QD.PO

Valsartan 80mg/T (0.5TB) QD.PO

Amlodipine Besylate 5 mg/T (1TB)

QD.PO

Diltiazem 30 mg/Tab (1TB) STAT.TID.PO

Nicorandil 20 mg/Tab (1TB) BID.PO

Isosorbide Dinitrate 10 mg/T (1TB)

QID.PO

Bisoprolol 5 mg/T (0.5TB) QD.PO

Nicametate Citrate 50 mg/T (1TB) TID.PO

Flunitrazepam 2 mg/T (1TB) HS.PO

Zopiclone 7.5 mg/Tab (1TB) HS.PO

Diphenidil 25mg/Tab (1TB) STAT.P

4141

Clonazepam 0.5 mg/Tab (1TB) TID.PO STAT

Imipramine 10 mg/T (1TB) HS.PO

Sato syprup 120 mg/BT (複方 ) (適量 1BT)

TID.PO

Omeprazole Infusion 40 mg/VI (1VI)

Q12H.IVD STAT

Amoxicillin 250 mg/Cap (4Cap) BID.PO

Clarithromycin 250 mg/T (2TB) BID.PO

Rabeprazole 20mg/Tab (1TB) QD.PO

Meperidine 50 mg/ml/Amp (1 Amp) STAT.IVD

Castor oil 30 mg/BT ( 20 ) STAT.PO STAT

Bisacodyl (栓劑 ) 10 mg/supp. (2 supp.)

STAT.RECT

Bisacodyl 5 mg/T (2TB) QD.PO STAT

Meclizine HCl 25 mg/Tab (1TB) TID.PO

Butylscoplamine 20 mg/cc/Amp (1 Amp)

STAT.IVD

Mucaine Tab (複方 ) (1Tab) TID.PO

Posterisan Forte Oint. 10gm/Tube (適量 1TU)

QD.EXT

4242

Discharge DiagnosisDischarge Diagnosis Chronic ischemic heart disease.Chronic ischemic heart disease. Hypertensive heart disease.Hypertensive heart disease. Gastric ulcer.Gastric ulcer. Gout arthritis.Gout arthritis. Chronic renal insufficiency.Chronic renal insufficiency. Dizziness and giddiness.Dizziness and giddiness. Degenerative joint disease.Degenerative joint disease.

4343

RecommendationsRecommendations ＆＆ MedicationsMedicationsItem Dose Frequency Dosage

Amlodipine Besylate 5 mg/T 1TB QD PO

Bisoprolol 5 mg/T 0.5TB QD PO

Valsartan 80mg/T 0.5TB QD PO

Rabeprazole 20mg/Tab 1TB QD PO

Amoxicillin 250 mg/Cap 4Cap BID PO

Clarithromycin 250 mg/T 2TB BID PO

Bisacodyl 5 mg/T 2TB QD PO

Flunitrazepam 2 mg/T 1TB HS PO

4444

Problem ListProblem List

4545

Problem 1

Amlodipine Besylate, Bisoprolol, Valsartan 適合用在治療患有 Chronic ischemic Chronic ischemic heart diseaseheart disease 及及 Hypertensive heart diseaseHypertensive heart disease 的年老患者身上嗎的年老患者身上嗎 ??

Chronic renal insufficiencyChronic renal insufficiency 患者服用此三類藥應當如何劑量患者服用此三類藥應當如何劑量 ??

Item Dose Frequency Dosage

Amlodipine Besylate 5 mg/T 1TB QD PO

Bisoprolol 5 mg/T 0.5TB QD PO

Valsartan 80mg/T 0.5TB QD PO

Rabeprazole 20mg/Tab 1TB QD PO

Amoxicillin 250 mg/Cap 4Cap BID PO

Clarithromycin 250 mg/T 2TB BID PO

Bisacodyl 5 mg/T 2TB QD PO

Flunitrazepam 2 mg/T 1TB HS PO

4646

The elderly hypertensive patient (>60 years) :The elderly hypertensive patient (>60 years) : ----CCB CCB ((Amlodipine Besylate) decrease vascular decrease vascular

resistance, have no adverse effects in lipid levels, are resistance, have no adverse effects in lipid levels, are good choices for elderly.good choices for elderly.

--Even though elderly patients tend to have low plasma --Even though elderly patients tend to have low plasma renin activity,renin activity, ACEIACEI and and ARBARB ( (Valsartan)) may be effective may be effective agents in this population.agents in this population.

--Long-term studies have documented the safety and --Long-term studies have documented the safety and efficacy of efficacy of BB BB ((Bisoprolol), especially after acute MI., especially after acute MI.

The hypertensive patient with coronary artery disease: --is at increased risk for unstable angina and MI, BB

((Bisoprolol) may be used as first-line agents in these patients.

The Washington Manual of Medical Therapeutics, 29th Edition

4747

Amlodipine Besylate --Dosage Oral: Hypertension: initial, 5 mg once daily; maintenance 5-10 mg once daily. Elderly, fragile, or small: for hypertension, or when adding to other antihypertensive therapy starting dose 2.5 mg once daily. Bisoprolol: -- Dosage Oral: Hypertension (JNC 7): 2.5-10 mg once daily. Elderly: initial,2.5 mg/day, may be increased by 2.5-5 mg/day; maximum recommended dose, 20 mg/day. ClCr < 40 mL/min: Initial: 2.5mg/day.

Valsartan: --Dosage Oral: Hypertension: Initial: 80-160 mg once daily ( In patients who are not volume depleted ); maximum recommended dose: 320 mg/day. The Washington Manual of Medical Therapeutics, 29th Edition Drug Information Handbook, 13th Edition. Drug Facts and Comparisons, 2006.

4848

Item Dose Frequency Dosage

Amlodipine Besylate 5 mg/T 1TB QD PO

Bisoprolol 5 mg/T 0.5TB QD PO

Valsartan 80mg/T 0.5TB QD PO

Rabeprazole 20mg/Tab 1TB QD PO

Amoxicillin 250 mg/Cap 4Cap BID PO

Clarithromycin 250 mg/T 2TB BID PO

Bisacodyl 5 mg/T 2TB QD PO

Flunitrazepam 2 mg/T 1TB HS PO

Rabeprazole, Amoxicillin, Clarithromycin, 適合用在 Gastric ulcerGastric ulcer 的患者上嗎的患者上嗎 ?? Chronic renal insufficiencyChronic renal insufficiency 患者服用此三類藥應當如何劑量患者服用此三類藥應當如何劑量 ??

Problem 2

4949

Reflux esophagitis: --symptomatology includes heartburn, dysphagia, chest pain, and

variety of ear, nose, and throat symptoms (hoarseness, sore throat). The lower esophageal sphincter (LES, e.g., theophylline, CCBs, BB, nitrate, anticholinergics.) is the major barrier against reflux.

Rabeprazole: --short-term (4-8 weeks) treatment and maintenance of erosive or

ulcerative GERD with Helicobater pylori infection. Dosage Oral: Adults > 18 years and elderly: GERD: 20 mg once daily for 4-8 weeks; maintenance: 20 mg once

daily. H. pylori eradication: 20 mg twice daily for 7 days; to be

administered with amoxicillin 1000 mg and clarithromycin 500 mg, also given twice daily for 7 days. All 3 medications should be taken twice daily with the morning and evening meals.

The Washington Manual of Medical Therapeutics, 29th Edition Drug Information Handbook, 13th Edition. Drug Facts and Comparisons, 2006.

5050

Item Dose Frequency Dosage

Amlodipine Besylate 5 mg/T

1TB QD PO

Bisoprolol 5 mg/T 0.5TB QD PO

Valsartan 80mg/T 0.5TB QD PO

Rabeprazole 20mg/Tab 1TB QD PO

Amoxicillin 250 mg/Cap 4Cap BID PO

Clarithromycin 250 mg/T 2TB BID PO

Bisacodyl 5 mg/T 2TB QD PO

Flunitrazepam 2 mg/T 1TB HS PO

5151

Punting

5252

Plan

5353

1.病人預出院前，出院準備小組護理師開出臨床藥學科用藥指導會診單

2.經由負責藥師確認後，有足夠時間至病床邊提供用藥指導

3.藥師先評估用藥合理性，必要時請醫師修改適合之藥物

4.與主護護士連繫，確認用藥指導之時間及指導對象

7.指導病人或照顧者用藥注意事項

5.依約定時間至病房

6.查詢病人電子病歷並記載所需資料

8.請被指導者回覆示教 

中國醫藥大學附設醫院作業標準書

5454

床 號： 性別：男 女 年 齡： 出院日期： 主治醫師：

姓 名： 體重： kg 職 業： 衛教日期： 藥師：

病歷號： 身高： cm 住院日期： 花費時間：衛教時間： 準備時間：

覆述結果：1.優 4.不佳2.良好 5.沒反應3.尚可住院診斷：如醫囑單

其他NIL電話：

使用藥物：如醫囑單所列藥物內容補充說明：

提供用藥指導單張

過敏紀錄：NKA

特別指導

指導對象： 本人 家屬 看護 外傭 朋友

衛教內容： 適應症、作用 用法 用量 服藥時間 注意事項 保存方式

中國醫藥大學附設醫院預出院病患用藥衛教記錄表

5555

23

17

29

38

52

35

14

29

24

42

51

27

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11 12

96年出院衛教人數統計

月份份

人數

Total: 374

5656

5757

衛教科別

Total: 159數據收集自 96.10~97.03

一般內科 16 骨科 3 急重症外科 6

心臟科 12 腎臟科 17 神經外科 50

心臟血管外科 1 感染科 6 胸腔科 46

耳鼻喉科 3 新陳代謝科 2 肝膽腸胃科 1

血液腫瘤科 3 直腸外科 2 免疫風濕科 1

5858

¤H¼Æ

0

20

40

60

80

100

120

140

160

數據收集自 96.10-97.03

Total: 159

不佳 尚可 良好 優良

29

136

12

5959

姓 名： 性別：男 女 年 齡： 住院期間： 主治醫師：病歷號： 體重： kg 職 業： 語 言： 藥師： 科 別： 身高： cm 教育程度： 衛教日期： 花費時間：電聯追蹤回覆結果： 1.優 2.良好 3.尚可 4.不佳 5.沒反應※提醒病患內容包括：藥物適應症、用法、用量、服藥時間、注意事項、保存方式及是否服用保健食品或其他藥品等。

用藥遵醫囑性： good doubtful（含糊、不明確的） poor主要問題： 忘記 不瞭解 故意不遵從用藥醫囑性

補充說明：

電聯追蹤對象： 本人 家屬（請註明： ） 外傭 看護 朋友藥師於床邊用藥衛教滿意度：1.非常滿意 2.滿意 3.普通4.不滿意 5.非常不滿意

使用藥物品項： 種

中國醫藥大學附設醫院出院病患床邊用藥衛教電聯追蹤評估表

註解定義 : 1.優：表示現用藥物內容全部答對 ; 2.良好：表示現用藥物內容超過三分之二以上答對 ; 3.尚可：表示現用藥物內容答對一半 ; 4.不佳：表示現用藥物內容只答對三分之ㄧ以下 ; 5.沒反應

6060

數據收集自 96.10-97.03

¤H¼Æ

0

10

20

30

40

50

Total: 48

普通 滿意 非常滿意 不滿意

2

42

4

0

6161

6262

～　謝謝聆聽　～

6363

Patient-oriented: For or interested in a particular type of person or thing.

Patient assessment: The critical analysis and evaluation or judgement of the status or quality of particular condition, situation or other subject of appraisal.

Patient safety: 對於健康照護過程中引起的不良結果或損害所採取的避免、預防與改善措施。

6464

評分標準