The mistake in writing instructions of nursing documents is that they should be signed by the attending physician.

Medical record is an important file of the hospital, also known as medical record, which is named "medical record" by the Ministry of Health in China. Medical records are all medical and nursing records of patients seeking medical treatment, which are composed of outpatient medical records and inpatient medical records. Outpatient medical records include the first item, the second page and various inspection reports.

Hospital medical records include ① medical records, which are records of medical history, examination, diagnosis and treatment collected by doctors, including doctor's orders, admission records, course records, medical records, discharge records, professional transfer records, consultation records, etc. (2) Nursing record means that the nurse records the patient's condition change, treatment and nursing measures.

There are temperature sheets, doctor's orders, doctor's orders records, special nursing records, nursing handover records, and responsible nursing records. (3) Inspection records refer to various inspection reports and diagnostic inspection reports, including electrocardiogram, chest radiograph, isotope, ultrasound, pathological examination report and endoscopic examination report. (4) all kinds of documents, including the relevant certificates of the patient's unit, hospitalization notice, critically ill notice, etc.

The doctor's advice:

The contents of doctor's orders include date, time, bed number, name, nursing routine, nursing level, diet, lying position, isolation type, drug treatment and other treatments (drug treatment should indicate drug name, concentration, dosage, usage and time; Surgical treatment should indicate the operation time, anesthesia type, operation name, preoperative medication, etc. ), special inspection and laboratory inspection and doctor's signature.

The doctor's order is the specific measures of examination, treatment and nursing formulated by doctors for patients, and it is the basis for nurses to check the diagnosis and treatment plan. The doctor wrote it and the medical staff performed it.

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 and execution nurse's signature.

The contents of temporary medical orders include the time of medical orders, the contents of temporary medical orders, the doctor's signature, the execution time and the execution nurse's signature.