The principle of processing is to deal with things urgently and then slowly, and execute first and then copy. That is, the temporary medical order is executed first, then the long-term medical order is executed, and finally it is copied to the medical order record sheet.

1. When executing the temporary medical order, use a pencil to draw an equal check mark in the marked column of the medical order, indicate the execution time and sign; after execution, copy the medical order to the temporary medical order column of the medical order record sheet and write "Execute" Time and sign, and use a blue pen to make a matching check mark in the marked column of the doctor's order book.

For temporary medical orders that have not yet been executed or need to be executed the next day, draw “△” with a pencil in the marked column of the medical order and indicate it on the nursing shift record. After execution, erase the pencil “△” and follow the temporary medical order. The processing and execution time are written as time/date, such as 7:20/4-30.

2. Copy the long-term medical orders to the execution sheet respectively. After each medical order is processed, immediately write it in the medical order book Use a red pen to draw an equal hook in the marked column; copy the processed medical orders into the long-term medical order column of the medical order record sheet, and use a blue pen to draw an equal check in the marked column of the medical order book.

3. Standby medical orders

(1) Long-term standby medical orders should be processed as long-term medical orders. The interval between each medication must be indicated. The nurse will record it in the temporary medical order column after each execution. , for the next class’s reference.

(2) Temporary backup medical orders are valid within 12 hours. There are also day and night backup orders. That is, day backup orders are only valid during the day. If they are not used during the day, they will expire at 7:00 pm. Night backup orders are only valid at night. If they are not used at night, they will expire at 7:00 the next morning. later failed. When canceling, the nurse will write "not used" with a red pen after the medical order; after execution, it will be handled according to the temporary medical order.

4. When stopping the doctor's order, draw a red line on the relevant execution sheet or small card and write down the stop date to indicate cancellation (no line is needed on the diet list, just continue to write the new order under the original diet type) diet, it means that the original diet has been invalidated and a new diet will be implemented), and use a red pen to draw an equal hook in the marked column of the medical order; write the stop date and time in the stop column behind the original medical order in the long-term medical order column of the medical order record sheet, And use a blue pen to draw an equal check in the marked column of the doctor's order examination and large collection.

5. For medical orders for surgery, delivery, and transfer, draw a red line on the original medical order on each execution sheet and write down the date. Use a red pen to draw an equal check mark in the marked column of the medical order book; in the temporary medical order column, Write down the date, time, and reason, and draw a red line under it to indicate that all previous medical orders are invalid. Use a blue pen to draw an equal check mark in the marked column of the medical order book.

6. For discharge, transfer, and death orders, mark all medical orders on the execution form with a red line, write the date, and mark the corresponding check with a red pen in the column of the medical order book; write the date in the temporary medical order column. , time, and reason, use a blue pen to mark the corresponding check in the marked column of the doctor's order book.

7. If the doctor’s order is to perform a drug allergy test and the test result is a positive reaction, put brackets after the doctor’s order and write “+” in the brackets with a red pen; if there is a negative reaction, write it in the brackets with a blue pen. "Ο" means. The test results should also be marked in the temporary medical order column copied to the medical order record sheet. For those with positive reactions, a red pen should be used to indicate that they are allergic to ×× drug in the upper left corner of their medical record folder. Long-term medical orders must be transferred after the test results are negative.