Doctor order checking is an indispensable and important step before, during and after nurses implement medical orders and implement care and treatment. It is directly related to patient safety, care and treatment effects, and is the most important and fundamental nursing care. One of the systems.
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The medical order checking system mainly has the following four items:
1. Medical orders must be verified by the doctor before being executed by the nurse. Questionable medical orders must be clarified before execution;
2. Under normal circumstances, doctors are not allowed to issue oral medical orders. When oral medical orders need to be given to rescue critical patients, the nurse should repeat them. After the rescue is completed, the records should be made according to the facts immediately;
3. Temporary medical orders with specified execution time should be strictly executed within the specified time. After the medical order is executed, the executor shall indicate the execution time and sign;
4. The medical order must be checked every shift, twice a week. :
Doctor's orders are the doctor's instructions for the patient's diet, medication, laboratory tests, etc. based on the patient's condition and treatment needs. Medical orders refer to medical instructions issued by physicians in medical activities. The content of the medical order and the start and stop times should be written by the physician. The contents of medical orders should be accurate and clear. Each medical order should contain only one content and indicate the time of issuance, which should be specific to the minute. It is divided into three categories: long-term medical orders, temporary medical orders and backup medical orders.