1, the drug name is Latin, English and Chinese, and the chemical molecular formula is not allowed.
2. Use the full name of the drug or the prescribed drug abbreviation, and do not use the homemade drug abbreviation.
3. The concentration of liquid must be written, and the concentration of mixture need not be written.
4. The dosage form should be indicated before the drug name, but commonly used drugs can be omitted.
5. Liquid is expressed in milliliter (ml), and solid is expressed in gram (g) or mg (mg) or microgram (ug). When the unit is gram, the unit gram can be omitted.
6, drug name, dosage, unit, usage font should be consistent, that is, English in English, Chinese in Chinese, Chinese and English can not be mixed.
7, fill in the date and time before each doctor's advice, and sign after the doctor's advice.
8. When intravenous injection of several drugs, first write the name of the solvent in which the drug is dissolved, and then write the name of the drug in order of priority. Usage in a new line, and indicate the number of drops.
9. All sensitive drugs should be recorded on the temporary doctor's list. Doctors draw blue brackets after drugs, and red "+"-"indicates" allergic "and" non-allergic "after drug testing. For example, penicillin allergy is expressed as penicillin [color = # 000080] [size = 9pt] [/size] [/color] [
[/size][/color] 10。 Cancel the doctor's advice Mark the word "cancel" in red in the time column of doctor's advice execution. Four, the writing order of long-term doctor's advice:
The first nursing routine, such as internal medicine nursing and pediatric nursing.
Secondary care, such as primary care and secondary care.
The third diet, such as general food and semi-liquid food.
The fourth item is seriously ill and dying, such as general diseases, so don't write it.
The fifth lying position, such as semi-lying position, is absolutely bedridden.
The sixth special treatment, such as measuring blood pressure, R, P every half hour, atomizing inhalation.
Item 7: Drugs should be written in the order of vein, muscle and oral administration. Temporary medical advice:
Write in chronological order of processing. Five, sorting out the doctor's advice in places where there are too many changes or effective doctor's advice is scattered, in order to be clear at a glance and prevent mistakes, the doctor's advice should be sorted out. Under the original doctor's orders, separate them with a red horizontal line, indicating that the above-mentioned doctor's orders are invalid, and mark the words "Reorder the doctor's orders" under the red line to sort out the orders that have not stopped. If there is a major change or surgery, the above-mentioned doctor's advice is invalid with a red line at the bottom of the last doctor's advice, and the "professional doctor's advice", "postoperative doctor's advice" and date are marked offline.
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(1) The doctor's advice is copied on the doctor's advice list in chronological order, and each line of the doctor's advice is written in the top box, with the first word aligned; When writing the second line, the unfinished content of one line should go back one space; If the second line is not finished, the third line should be aligned with the first word of the second line.
(2) Long-term doctor's advice should be copied in the long-term doctor's advice column, indicating the date and specific time; Stop the doctor's advice, and then write down the date and specific time in the stop column of the original doctor's advice.
(3) Long-term standby doctor's advice column should be filled with long-term standby doctor's advice (PRN), and the execution time of the last doctor's advice should be checked before execution; After each execution, records should be made in the temporary doctor's advice column, and the execution time should be indicated.
(4) temporary doctor's advice column copy temporary doctor's advice, write the execution time.
(5) After the implementation of the temporary standby medical advice (SOS), it will be copied in the temporary medical advice column, and the unused ones will not be copied.
(6) After the drug allergy test, the results should be filled in the temporary doctor's advice column. Positive responders should be marked with "+"in red ink pen to show their attention, recorded on the temperature list, and marked prominently on the head card and outpatient medical record card. The executor shall sign the corresponding column of the doctor's advice book.
(7) The doctor's advice has been copied and then invalidated. Write "invalid" in the execution time column with blue and black ink pen.
(8) When changing majors, operations, childbirth or arranging doctor's advice, draw a red horizontal line below the last doctor's advice, indicating that the above doctor's advice will be stopped; In the case of rearranging the doctor's advice, write "Reorder the doctor's advice" and the date in the long-term doctor's advice column with a red pen under the red line. When sorting out doctor's orders, we must sort out and accurately copy the effective long-term doctor's orders, and specify the date and specific time of the original doctor's orders. Arrange the nursing level, diet, serious illness, escort and other medical orders in front, and copy the medical orders according to the original date. If there are spaces, draw a diagonal line from left to right with a red ink pen.
(9) If the patient changes major, leaves the hospital or dies, the time of changing major, leaving the hospital and notifying death should be indicated in the temporary medical advice column, and all medical advice on the relevant implementation list should be stopped.
(10) Seriously implement the inspection system. After the doctor's advice is processed, it needs to be checked once a week by the checker.
(1 1) If there are many doctor's orders and one doctor's order is not enough to record, one page can be continued, and the unused parts are still copied in the original format.