Doctor's order refers to the medical instructions issued by doctors in medical activities, which formulate various specific measures for the diagnosis and treatment of patients. The doctor's order must be filled out by the attending doctor himself, and it is only effective for the intern to fill it out with the consent of the teacher.
(a) the contents of the doctor's advice and the starting and ending time shall be written by the doctor.
(two) the contents of the doctor's advice should be accurate and clear, each doctor's advice contains only one content, and indicate the release time, specific to minutes.
(three) the doctor's advice shall not be altered, and when it needs to be cancelled, the word "cancel" shall be written in red ink on the second word of the doctor's advice and signed.
(4) In general, doctors may not give oral orders. When it is necessary to give oral medical advice in rescuing critically ill patients or during surgery, the nurse should repeat it, and it can only be carried out after being examined by the doctor. After the rescue, the doctor should fill the doctor's advice truthfully immediately.
(5) the doctor's advice type:
1, long-term doctor's advice-refers to more than two routine doctor's advice, which is valid for more than 24 hours and expires after the doctor indicates the stop time.
2. Temporary medical orders refer to complete medical orders, diagnosis, inspection, disposal and temporary medication, and the effective time is within 24 hours. The contents of temporary medical orders include the time of medical orders, the contents of temporary medical orders, the signature of doctors, the execution time and the signature of nurses.
3, standby doctor's advice-also known as "predictive doctor's advice", according to the needs of illness, divided into long-term standby doctor's advice (prn doctor's advice) and temporary standby doctor's advice (sos doctor's advice). Long-term standby orders valid for more than 24 hours are invalid only after the doctor indicates the stop time. Temporary standby doctor's advice is only valid within the specified time, and it will be invalid if it is not implemented after the expiration.
(6) The writing order of doctor's advice:
1, long-term doctor's advice:
The first nursing routine, such as internal medicine nursing and pediatric nursing.
Secondary care, such as primary care and secondary care.
The third diet, such as general food and semi-liquid food.
The fourth item is seriously ill and dying, such as general diseases, so don't write it.
The fifth lying position, such as semi-lying position, is absolutely bedridden.
The sixth special treatment, such as measuring blood pressure, R, P every half hour, atomizing inhalation.
Item 7: Drugs should be written in the order of vein, muscle and oral administration.
2. Temporary medical orders: written in chronological order.
The order of long-term doctor's advice is: nursing routine, nursing level, critical or serious illness, isolation type, diet type, body position, various examinations and treatments, drug name, dosage and usage.
(7) Requirements for writing doctor's advice
(1), the doctor's advice should be written near the date line, without spaces, and the lines should be aligned; When one line is not enough to start another, the front should be empty; If there is only dosage and time left, write it on the second line with the tail. If the same patient has several orders at the same time, only the first and last lines need to indicate the time, and the rest are connected by straight lines.
(2) If the same patient has more than one doctor's order and the time is the same, the signer only needs to stamp the first and last lines, and the rest items are connected by straight lines; After the temporary medical order is executed, the executor must sign and indicate the execution time.
(3) Long-term doctor's advice: if the effective time exceeds 24 hours, it will be invalid after the doctor indicates the stop time. Generally, it should be prescribed before 10 am, and then concentrated treatment, such as changing majors, surgery, discharge, death, the doctor's advice will automatically stop.
(4) Temporary medical advice: the effective time is less than 24 hours. Temporary doctor's order is a one-time treatment or rescue order decided by the doctor at any time according to the condition, including taking medicine after discharge. Temporary medical orders can only be executed once, including oral medication, injection, preoperative medication, special treatment, examination and skin test. In addition to preparing the first doctor's order before operation, such as "appendectomy under epidural anesthesia at 8 am tomorrow", it is also necessary to specify the specific execution time.
5. Drug names should be in Chinese and English, and chemical molecular formulas are not allowed.
[6], can use the abbreviation of the name of the whole drug or the provisions of the drug name, not homemade drug name abbreviation, and indicate the dosage form.
Once, the concentration of liquid must be written, and the concentration of mixture need not be written.
(8) Liquid is expressed in milliliters (ml), and solid is expressed in grams (g) or milligrams (mg) or micrograms (ug). When the unit is gram, the unit gram can be omitted.
(9) The font of drug name, dosage, unit and usage should be consistent, that is, English should be used in English, and Chinese should be used in Chinese, and Chinese and English should not be mixed.
⑽. When several drugs are injected intravenously, first write the name of the solvent that dissolves the drug, and then write the name of the drug in the order of primary and secondary. Usage in a new line, and indicate the number of drops.
⑾. All sensitive drugs should be recorded on the temporary doctor's list. The doctor draws blue brackets after the drugs, and the operator and other two people judge the results after the drug sensitivity test. The red "+""-"is recorded in "()", indicating "allergy" and "no allergy". The two signed their full names. Representative: Assist the judge/operator.
⑿, cancel the doctor's advice in the doctor's advice execution time bar with a red mark "cancel".
[13], surgery, childbirth, change one's major doctor's advice, should draw a red line under the last doctor's advice, said before the doctor's advice shall be invalid; Mark "Post-operation doctor's advice" and "Change your professional doctor's advice" in the center of the line with blue-black (carbon) ink pen, and indicate the date and time of the day in the date and time column.
[14], more than three long-term doctor's orders should be sorted out in time. The valid long-term doctor's orders and the original doctor's orders should be copied, and the doctor who rearranged the doctor's orders should sign in the doctor's signature column.
Second, the writing format of doctor's advice
(1) Long-term medical advice
Project content remarks
Nursing routine plastic surgery nursing routine
Internal medicine nursing routine
General surgical nursing routine
Nursing routine of cardiac surgery
Coma nursing routine
Nursing Routine of "Prosthetic Breast Augmentation Surgery"
Nursing care after intravenous anesthesia
Nursing special care
First-class nursing
Secondary nursing
Three-level nursing
* Major illness or notification of serious illness
be in a critical condition
* isolated respiratory isolation
Eye, nose and mouth care (skin care)
Bedside isolation
Ordinary diet
liquid diet
Semi-liquid diet or semi-liquid diet
quick
After 6 hours of anesthesia, she changed to a semi-liquid diet.
Low salt diet
Diabetes diet
Nasal feeding liquid diet
high-protein diet
Low salt and high protein diet
Semi-liquid high protein diet
* Are you with someone?
Posture requires supine position.
Semi-reclining position
Lift the affected limb
* T R P BP is used for special examination and treatment once an hour.
Continuous low flow oxygen inhalation
Record the inflow and outflow for 24 hours.
Restrict water inflow (
Aspiration of sputum when necessary.
The nasal catheter inhales oxygen for 3~5 liters/minute.
Blood pressure, pulse, respiration, temperature measurement 1 time /2 hours.
Indwelling catheter
Indwelling catheter connected to negative pressure bottle
Indwelling analgesia pump
Indwelling gastric tube connected with negative pressure bottle
* Drug name, dosage and usage: Take the medicine first, then inject it.
Inject 500 ml of normal saline.
Penicillin injection16.4 million USD.
Intravenous drip 60gtt/min once a day.
Vitamin c tablets 0. 1 tid po
(2) Temporary medical advice
Blood analysis+blood type
Urine analysis
Fecal routine
electrocardiogram
Full chest film (positive position)
Ultrasound examination of breast
fasting blood-glucose
Coagulation four items (PT+APTT+TT+Fbg)
liver function
Two halves of hepatitis B.
anit hcv
AIDS antibodies
Syphilis antibody
kidney function
Electrolyte (potassium+sodium+chlorine-calcium++)
Gastroscopy
Gastroenterology consultation
Rescue once.
Penicillin skin test ()
cross matching
Prepare "O" type concentrated red blood cells 2U
Talk to the patient and sign it.
It is planned to implant prosthesis for breast augmentation under intravenous anesthesia today 14: 00.
preserved skin
Preoperative fasting 12 hours, drinking for 4 hours.
Lumina 0. 1 30' before operation
Atropine 0.5 mg intramuscular injection
(3) Blood transfusion orders:
Pre-transfusion examination:
1, blood analysis+blood type (required), such as "O" blood patients.
2, bone marrow puncture examination
3, bone marrow iron staining examination
4. Determination of serum ferritin
5. Determination of Transferrin Receptor
6. Determination of serum iron and total iron binding capacity
7. Serum transferrin saturation
8, blood smear to observe the morphology of red blood cells.
9, liver function (necessary)
10, two halves of hepatitis B (required)
1 1, hepatitis C antibody (required)
12, serological detection of syphilis (required)
13, HIV12 antibody (required)
14, cytomegalovirus antibody (optional)
15, EB virus detection (optional)
16, prepare 2 units of O-type concentrated red blood cells.
17, cross matching
18, 2 units of O-type concentrated red blood cells were infused, and 30gtt/min was given intravenously.