First of all, the principles are as follows:
1, the doctor's advice must be signed by a doctor to be effective. Generally, oral orders are not executed. When dealing with doctor's orders, we should be urgent first and then slow down, that is, we should implement temporary doctor's orders first and then long-term doctor's orders.
2, the doctor's advice in question should be executed after the query. Check the doctor's advice every class, every day, every week, and sign the full name after checking.
3, anyone who needs the next temporary doctor's advice should be succession, and indicate it in the nurse's log record. Any doctor's advice written in the doctor's advice book that does not need to be executed shall not be pasted or altered.
Second, the matters needing attention when dealing with doctor's advice:
1, the doctor's order must be signed by a doctor. The doctor's advice in doubt should be checked before implementation. The writing and execution time of medical orders is 24 hours.
2. Any doctor's advice that has been written in the doctor's advice book and does not need to be executed shall not be stamped or altered. The doctor should write "cancel" in red pen and sign his full name in blue pen after the doctor orders.
3, the doctor's advice should be collected every BANCHA, medical education network, always check once a week. Any temporary medical orders that need to be carried out at the next place should be handed over and marked on the nurse's handover record.
Expand:
1. Basic patient information: patient's name, gender, age, hospitalization number, ward, bed number and other information.
2. Items of medical orders: Doctors should specify the contents of medical orders, including drugs, dosage, route, frequency, course of treatment and other information.
3. The signer of the doctor's order: the doctor should sign his name, title, department and signing time on the doctor's order to show that the doctor's order is signed by himself.
4. Execution time of doctor's orders: doctors should specify the execution time of doctor's orders to ensure that the doctor's orders can be executed in time and achieve therapeutic effect. ?
5. Stop time of doctor's advice: Doctors should specify the stop time of doctor's advice so that nurses and doctors can stop the doctor's advice in time.
6. Purpose of doctor's advice: Doctors should make clear the therapeutic purpose of doctor's advice, so that nurses and doctors can correctly carry out doctor's advice and achieve therapeutic effect.
7. Review of doctor's orders: Doctors should review doctor's orders to ensure their accuracy and safety.
8. Sign for the doctor's advice: the nurse should sign for it before executing the doctor's advice, and record the implementation in time after execution. ?
In short, a standardized medical order should clearly state the contents, execution time, stop time, purpose and audit information of the medical order to ensure the accuracy and safety of the medical order. At the same time, doctors and nurses should strictly abide by medical norms and operating procedures to ensure medical quality and patient safety.