Can temporary medical orders be recorded when they are executed?

Yes, the nurse carries out the doctor's advice system Part I: The nurse carries out the doctor's advice system 1. After the doctor gives a doctor's order, he should register it in the doctor's order book and give it to the main nurse. Drug orders must indicate the date, time, usage and dosage (the unit must be indicated). If the doctor fails to register in the doctor's order book or execute the doctor's order on time, the doctor shall be responsible; if the nurse fails to execute the doctor's order on time or executes the doctor's order wrongly due to lax control, the nurse shall be responsible. 2. To accurately execute the doctor's advice on time, whether it is a long-term doctor's advice or a temporary doctor's advice, the nurse should record the execution date and time after each execution, and sign the full name on the doctor's advice execution form. 3. The suspicious doctor's advice, must find out the query rear can perform. Nurses need to ask the author to rewrite the doctor's orders in an irregular way. Oral orders shall not be executed except in rescue or operation. If the doctor needs to give an oral medical order, the nurse should repeat it, and it can only be carried out after verification, and keep the medicine ampoule empty. After the rescue or operation, the doctor should fill the doctor's advice in time and truthfully. It is forbidden for doctors to prescribe without looking at patients. Where this phenomenon exists, nurses should resolutely refuse to carry it out. 5. After the operation and delivery, stop the preoperative and prenatal doctor's advice, reopen the doctor's advice, and handle it according to the procedure. 6. All temporary orders that need to be executed in the next shift should be clear and marked on the corresponding records. 7. When the doctor has no doctor's advice, nurses are generally not allowed to give patients symptomatic treatment. However, in case of emergency rescue of critically ill patients without the doctor, the nurse can temporarily give necessary treatment within the scope of the nurse's duties according to the condition, but should make records and report to the attending doctor in time. 8. The doctor's advice should be checked in shifts, every day and every Friday afternoon (the head nurse attends, and the doctor's advice list, treatment list, medication list, nursing list, etc.). , and take the form of crowding round to collect signatures). Chapter II: System and process of doctor's advice execution 1. Medical order execution system: 1. The doctor's advice must be issued by a doctor with two certificates (doctor's qualification certificate and practice certificate) and prescription right in our hospital. The doctor writes the doctor's orders directly in the doctor's book or on the computer. In order to avoid mistakes, nurses can't remember doctor's orders. 2. The personnel who carry out the doctor's advice must be qualified registered nurses in our hospital, and other personnel may not carry out the doctor's advice. 3. After the doctor gives orders on the computer, the nurse should check the correctness of the contents of the orders and the starting time, strictly implement the orders, and shall not change them without authorization. Temporary medical orders must be executed within the specified time of 15 minutes. If there is any doubt or ambiguity in the doctor's advice, it should be put forward to the doctor in time, and it can be implemented only after it is clear. When necessary, the nurse has the right to report to the superior doctor and head nurse, and shall not blindly implement it. If the doctor's advice cannot be carried out for some reason, it shall be reported to the doctor in time and handled. 3. The clerk of the ward nurse station is responsible for printing the doctor's advice execution form, which is checked and executed by the responsible nurse in charge of the bed. After the nurse in charge executes the doctor's advice, she signs the execution time and name on the doctor's advice execution list. 4. In the process of executing the doctor's advice, we must strictly abide by the checking system to prevent mistakes and accidents. When executing the doctor's advice, we must strictly implement the bedside double check system.

Under normal circumstances, nurses can't carry out doctors' verbal orders. When it is necessary to carry out oral medical advice to rescue critically ill patients, the nurse should correct it before carrying it out. After the rescue, the nurse should record the doctor's supplementary orders in time and sign the execution time and the name of the executor. 6. All temporary medical orders that need to be executed in the next shift should be made clear to relevant personnel, and the specimen containers and special inspection requirements (such as fasting and preoperative medication) should be prepared, and detailed handover should be made in the handover report. Nayong Xinli hospital After surgery, major change, discharge or death, patients should stop the previous doctor's advice in time, and re-execute the doctor's advice after surgery or major change. 8. The nurse should check the doctor's advice in each class. After taking over, they should check whether the doctor's advice of the previous class is handled perfectly. During the duty, they should enter the workstation at any time to see if there are any new doctor's orders. The head nurse always checks all the doctor's orders once a week. And sign the doctor's advice check register, and correct the mistakes immediately if found. Nursing department should regularly check the doctor's advice of each department. 9. When there is no doctor's advice, nurses are generally not allowed to give patients symptomatic treatment. However, in the emergency rescue of critically ill patients, if the doctor is not on the scene, the nurse can temporarily give necessary treatment according to the condition, but should make records and report to the attending doctor in time. 10. Accumulate the charges according to the doctor's advice and the charging standards of various disposal contents. Check the medical expenses of inpatients at any time and pay them in time. Attachment: doctor's advice type (1) Long-term doctor's advice: valid for more than 24 hours, and invalid after the doctor indicates the stop time. (2) Temporary medical orders: valid for less than 24 hours, should be executed in a short time, and immediately if necessary. (3) Standby doctor's advice: It can be divided into long-term standby doctor's advice (PRN) and temporary standby doctor's advice (SOS) according to the needs of illness. Second, the doctor's advice execution process: 1. After receiving the doctor's advice, the nurse carefully read and checked. 2. Check the doctor's advice and confirm it after no doubt. 3. The doctor's advice processing nurses according to the doctor's advice execution requirements assigned to the nurse's order. 4. The doctor's advice execution nurse after receiving the doctor's advice execution form, carefully check, in strict accordance with the requirements of the doctor's advice content and time accurately, shall not be changed without authorization. 5. After the doctor's advice is executed, the curative effect and adverse reactions should be carefully observed, recorded when necessary, and feedback with the doctor in time. Chapter III: Doctor's Order Execution System 1. The doctor's advice execution system (1) can only be executed if it is issued by a doctor with two certificates (doctor's qualification certificate and practice certificate) and prescription right in this medical institution. The doctor writes the doctor's orders directly in the doctor's notebook or on the computer. In order to avoid mistakes, nurses are not allowed to enter doctor's orders on their own behalf.

(2) After the doctor issues the doctor's advice, the nurse shall promptly, accurately and strictly carry out the doctor's advice, and shall not change it without authorization. If there is any doubt or ambiguity in the doctor's advice, it should be put forward to the doctor in time, and it can be implemented only after it is clear. (3) The clerk of the ward nurse station is responsible for printing the doctor's advice execution list, which is checked and executed by the bed nurse; After the nurse in charge carries out the doctor's advice, she signs the execution time and name on the execution list. (4) In the process of executing the doctor's advice, we must strictly abide by the checking system to prevent mistakes and accidents. When executing the doctor's advice, we must strictly implement the double check system. During blood transfusion, the bedside double check system must be implemented. (5) In general, the nurse shall not carry out the doctor's oral orders. When it is necessary to carry out oral medical advice to rescue critically ill patients, the nurse should correct it before carrying it out. After the rescue, the nurse should record the doctor's supplementary orders in time and sign the execution time and the name of the executor. (6) The doctor's orders of all patients in the ward must be checked once every day with the participation of the shift leader. The method is: the clerk (assistant nurse) of the ward nurse station printed out the medical order execution list of all patients in the whole ward at that time, and handed it over to the leader on duty and another responsible nurse to check the printed medical order together. Long-term or temporary medical orders that cannot be uniformly checked must be checked by a second person before implementation. (7) Ward doctor's advice execution list shall be executed by one person every day. The doctor's advice execution table is specially kept in the department. 2. Nursing guidance implementation system (1) Nursing guidance is a nursing measure issued by a senior responsible nurse, team leader or specialist nurse to help the responsible nurse achieve the expected nursing goal according to the patient's condition and nursing needs. Nursing guidance is a kind of nursing behavior to promote, maintain and restore patients' physical and mental health. (2) The nursing instructions must be issued or formulated by the senior responsible nurse or above. The senior nurse in charge will write the nursing instruction directly on the nursing instruction execution form. Nursing orders should be issued and adjusted at any time according to the doctor's orders, patients' condition and nursing needs. Before issuing a nursing order, the patient's condition and needs should be evaluated. (3) Nursing guidance shall be carried out by senior responsible nurses, (junior) responsible nurses or assistant nurses. Nurses at lower levels should promptly, accurately and strictly carry out nursing instructions, and shall not change them without authorization. If there is any doubt or ambiguity in the letter of protection. It should be put forward to the nurse at the next higher level in time, and it can be implemented only after it is clear. The responsible nurse who carries out the nursing instruction after carrying out the nursing instruction shall sign the full name on the "Nursing Instruction Execution Form". (4) Nurses at the next higher level, including specialist nurses, day (night) team leaders or specialist team leaders, evaluate the implementation and nursing effect of nursing instructions every morning through rounds, consultations and shifts, and change or adjust nursing instructions in time.

(5) Nursing should be carried out continuously with medical work. When the nursing instruction is inconsistent with the doctor's order, the nurse should communicate with the doctor in time and adjust the doctor's order or nursing instruction. (6) Nursing guidance should be based on the principle of guiding junior nurses to complete nursing work, and ensure the unity, homogeneity and continuity of nursing work. Chapter iv: implementing the medical advice system 1. Requirements for writing doctor's orders: 1. 1 When the doctor's orders are issued, the patient's name and bed number must be stated. 1.2 sequence: a. Specialized nursing routine and graded nursing; B. Key care (such as severe illness, serious illness, absolute bed rest, special posture, etc. ); C special records (such as recording inflow and outflow, measuring blood pressure regularly, etc.). ); D. diet; E. Treatment orders (summarized according to drug types, duration and methods for execution and printing); Inspection, testing, etc. 1.3 To stop using the doctor's advice, write "Stop using" first, and then specify the contents of stopping using the doctor's advice. 2. Sort out doctor's orders: For long-term doctor's orders, doctors should issue "reorganization" doctor's orders in time, and the main nurse is responsible for checking them. Draw a horizontal line with a red pencil under the last long-term doctor's order, and then arrange the uninterrupted doctor's orders in chronological order. 3. Carry out the doctor's advice: 3. 1 The nurse on duty must read the doctor's advice carefully and confirm the patient's name, bed number, drug name, dosage, frequency, usage and time before carrying out it. 3.2 When executing the doctor's advice, it must be carefully checked according to the check requirements. After the long-term doctor's advice is executed, immediately put a blue "tick" on the doctor's advice execution form and sign it. Immediately after the execution of the temporary medical order, sign the full name on the medical order form and indicate the actual execution time. 3.3 After treatment, the doctor's advice is confirmed by the nurse, printed on the doctor's advice list and the doctor's advice execution list, and then marked with blue "tick" in the doctor's advice book. 3.4 when necessary (P.R.N), the doctor's advice should be treated as a long-term doctor's advice, and it should be recorded on the doctor's advice list as a temporary doctor's advice every time it is executed. 4. Requirements: 4. 1 Regular medical orders are generally issued before 10Am, with clear levels and clear contents. 4.2 Medical staff must write medical advice for all the treatments of patients, and may not give oral medical advice (emergency treatment can be carried out for patients first, and then fill in the medical advice). 4.3 Written doctor's advice shall be legible, neat, clear and complete, and shall not be altered at will. Unused doctor's orders should be marked with the word "DC" in red pen to indicate their discontinuation, and all written, executed and "cancelled" doctor's orders should be marked with the time and full name. 4.4 Routine medical orders for examination, treatment, diet and nursing should be written in Chinese, and common names can also be abbreviated in foreign languages. 4.5 When patients undergo surgery or change their major, they should stop the preoperative doctor's advice or the original doctor's advice, and mark the deadline with a red pencil on the doctor's advice list to rewrite the postoperative doctor's advice and the doctor's advice after changing their major.

4.6 The doctor shall give an oral explanation to the nurse on duty after issuing special orders. 4.7 When the nurse executes the doctor's advice, it must be carefully checked by the second person. Check the doctor's advice and sign it in each shift. Check the doctor's advice comprehensively once a week. Eight. Graded nursing system 1. The temperature, pulse and respiration of the new patients were measured three times a day for three consecutive days; The temperature is above 37.5℃, and critically ill patients should be measured every four hours. Generally, patients have their body temperature, pulse and breathing measured once every morning and evening, and they are required to defecate once every day. Blood pressure and weight of newly admitted patients are measured once (blood pressure is exempted for children under seven years old as appropriate). Others are carried out according to routine and doctor's advice. 2. The doctor issued a graded nursing list according to the condition, and then marked the graded nursing. (1) Youfu 1. 1 Condition: A. Patients who are in critical condition and need to be rescued at any time. B. Patients after various complicated or newly developed major operations. Patients with severe trauma and extensive burns. D. Some serious medical diseases and mental disorders. E. various patients admitted to ICU 1.2 nursing requirements: a. unless the patient's condition suddenly changes, he must enter the intensive care unit or intensive care unit, and the nursing nurse or intensive care personnel will take care of him according to the doctor's advice. B closely observe the changes of the disease, measure the temperature, pulse, respiration and blood pressure at any time, keep the respiratory tract and various pipes unobstructed, and accurately record the 24-hour inflow and outflow. C. Make a nursing plan or nursing focus, have a complete intensive care record, and record the patient's condition changes in detail. D. Life care of critically ill patients is completed by nursing staff. E. Prepare first-aid medicines and instruments, change and disinfect materials regularly, and strictly implement aseptic operation procedures. F. Observe patients' emotional changes and do psychological nursing. G. special care should be provided by nursing nurses or special nursing staff. (2) Primary care 2. 1 Condition basis: A. Severe patients, patients who still need to stay in bed strictly after various major operations, and patients who can't take care of themselves. B. Patients who can take care of themselves, but their condition may change at any time. 2.2 Nursing requirements: a. Observe the changes of illness at any time, and regularly measure body temperature, pulse, respiration and blood pressure according to the illness. B. Strengthen basic nursing and specialized nursing to prevent complications. C. patrol the ward regularly and make all kinds of emergency preparations at any time. D. Observe the reaction and effect after medication, and make nursing records. E. Observe patients' emotional changes and do psychological nursing. F. Patrol every 30 minutes (3) Secondary care 3. 1 Condition basis: a. Patients whose acute symptoms disappear and their condition tends to be stable and still need bed rest; B. Patients with chronic diseases who have limited activities or take care of themselves for most of their lives. 3.2 Nursing requirements:

A. Patrol patients regularly, grasp the changes of patients' condition, and measure patients' temperature, pulse, respiration and blood pressure as usual; B. Assist, urge and guide patients in life nursing. C. write the general nursing record sheet as required. Patrol every one to two hours. (4) Three-level care 4. 1 Disease basis: patients who can take care of themselves completely, have mild illness or are recovering. 4.2 Nursing requirements: a. Take the patient's temperature, pulse, respiration and blood pressure as usual; B. Patrol patients regularly to master the treatment effect and mental state of patients; C. health education and rehabilitation guidance. 3. According to the condition change and evaluation results, change the nursing level in time. Attachment: Handling of Dead Patients 1. Only patients who have been confirmed dead by doctors can be disposed of, and nurses should give psychological comfort to their families. 2. The doctor fills in the death notice and sends it to the inpatient department, which will inform the family or unit of the deceased. 3. There should be two people present to check whether the deceased has any relics, such as money, tickets, clothes and other items, and give them to the deceased's family or unit. If the family members and units are absent, they shall be kept by the head nurse. 4. The nurse on duty should plug the mouth, nose, ears, anus and vagina of the deceased with cotton. If there is any wound or excrement, you should scrub the package to keep your eyes closed. Get dressed, wrap it in a big sheet, put a death sign, and notify Taiping of the indirect body. 5. Tidy up the ward and remove the sheets and bedding. Ventilation, disinfection of beds and bedside tables as usual. If the patient is infected, it should be treated according to the disinfection system of infectious diseases. 6. Organize medical records and complete nursing records. Chapter 5: Medical Order Execution System 1. Doctors' orders must be executed by doctors with two certificates (doctor qualification and practice certificate) and prescription right in this medical institution. The doctor writes the doctor's orders directly in the doctor's notebook or on the computer. In order to avoid mistakes, nurses are not allowed to enter doctor's orders on their own behalf. 2. After the doctor issues the doctor's advice, the nurse shall promptly, accurately and strictly implement the doctor's advice, and shall not change it without authorization.