The contents of doctor's orders should be accurate and clear, and each doctor's order contains only one content, and the release time should be indicated, specifically to minutes.
The doctor's advice cannot be changed. When cancellation is required, the word "cancellation" should be marked with red ink and signed.
Under normal circumstances, doctors may not give oral orders. When it is necessary to carry out oral medical advice to rescue critically ill patients, nurses should repeat it. After the rescue, the doctor should fill the doctor's advice truthfully immediately.
Medical orders are divided into long-term medical orders and temporary medical orders. The contents of the long-term medical order list include the patient's name, department, inpatient medical record number (or medical record number), page number, start date and time, long-term medical order content, stop date and time, doctor's signature, execution time, long-term medical order content, stop date and time, doctor's signature, execution time and execution nurse's signature. The contents of the temporary medical order list include the time of medical order, the contents of temporary medical order, the doctor's signature, the execution time and the signature of the executive nurse.
After doctors prescribe or rearrange orders, they need to be reviewed again. The nurse must find out the suspicious doctor's orders before carrying them out. It is strictly forbidden to prescribe medical advice without seeing the patient.
Nurses check the doctor's orders in each shift, check the doctor's orders in the night shift, and check the doctor's orders in the daytime by the head nurse and the main nurse every day. The head nurse organizes a general inspection once a week, and after copying and sorting out the doctor's orders, another person needs to check the execution of the other party.
Before and after the operation, the doctor should stop the doctor's advice automatically, and after the operation, the doctor should issue the doctor's advice in time. And copy it on the doctor's advice record sheet and each execution sheet respectively.
All medical orders that need to be executed in the next shift should be clearly explained and marked on the nurse's duty record.
Nurses are generally not allowed to treat patients when doctors have no orders. However, in an emergency, the nurse can temporarily give necessary treatment according to the condition, but should make records and report to the attending doctor in time.