In order to standardize the behavior of clinical medical staff in the process of issuing and executing medical orders, and ensure medical quality and medical safety, this system is formulated. The doctor's order must be an electronic or handwritten doctor's order issued by a medical practitioner who has obtained the right to prescribe with the approval of the Medical Administration Department of our hospital. Doctors without the right to prescribe can only prescribe under the guidance of teaching doctors.
It can only be sent after being examined and signed by the teaching doctor, and the legal responsibility arising from the doctor's advice shall be borne by the teaching doctor. Medical orders are divided into long-term medical orders, temporary medical orders and oral medical orders. The doctor's orders for inpatients are issued in writing by doctors in non-emergency situations. In principle, it is hierarchical, and the time should be accurate to the minute. Nurses should check the doctor's orders item by item and execute them, and sign the full name and execution time on the classified execution list.
Medical consultation system
Oral orders, only in emergency situations such as rescue and operation, doctors and anesthesiologists can give oral orders. In some special cases, doctors can't arrive at the scene immediately, and when they need immediate treatment, they can carry out telephone orders. In other cases, oral orders or telephone orders are not allowed.
In the case of emergency rescue, the nurse should completely confirm the patient's name, the contents of the doctor's order and repeat the contents of the doctor's order when carrying out oral or telephone orders. It can be carried out only after it is confirmed by the prescribing doctor and verified by two people. After the execution, the execution time should be recorded and signed. Within 6 hours after the rescue or operation, the doctor who gave the oral order will fill in the contents of the order.