The nurse can't transfer to and copy and duplicate the doctor's order

The nurse can't transfer to and copy and duplicate the doctor's order
The nurse can't transfer to and copy and duplicate the doctor's order
This newspaper reports (a reporter solves and shines the brightness) on March 29 "It is filled in with the blue-black, burnt black ink pen that the content wants, the writing is clear. The norm uses the medical terminology, the characters are careful and neat, the writing is clear, it is accurate to state, the sentence is clear and coherent, the punctuation mark is correct. " This is that a department of public health of the province fills in and attends to the requirement of the document for the unit nurse of medical treatment of our province. The department of public health of the province issued the notice a few days ago, had written and paid standardizing in attending to the document. Nurse need the intersection of nursing and document including operation in the intersection of body temperature and form, the intersection of doctor's order and form, course of disease record that fill in or write check and record and seriously ill (critically ill) The patient attends to and records and attends to and relieves in the report day and night. Our province stipulates, attend to and relieve in the report day and night and keep for one year in the department at least, do not include in the case and keep. Attending to the document should use Chinese to write, common foreign language abbreviation and there are not symptom, physical sign, disease name of the Chinese translated name formally,etc. can use the foreign language. The case history writes and uses Aeabic numeral to write date and time without exception, adopt for 24 hours and make the record. Case history write in the course appearing wrongly written charactering, should draw with double-line in the wrongly written character, clearly keep and record originally, can distinguish, and mark out and revises time and revise people and sign. Can't adopt the method of shaving, glueing, scribbling etc. to conceal or remove the original writing. At the beginning of performing the operation, apparatus nurse and circuit nurse must check, check the name, quantity of different apparatus and dressing in the operation bag, and fill in accurately item by item. Record in time of answering of apparatus, dressing added extra in the operation. Before the end of surgery, apparatus nurse and circuit nurse checked apparatus, dressing on the platform, under the platform together, confirm the quantity is checked, tell to a doctor. While checking, the quantity substantially as finding apparatus, dressing does not correspond to the skill, the nurse should require doctor look for the operation together in time, if operation doctor refuse, nurse should record clear, sign by doctor. Apparatus nurse, circuit nurse sign the full name in checking and recording the form. The skill is finished, the circuit nurse will perform the operation and check to record to put in patient's case history only, send back to the ward together. The doctor has a clear norm to make the doctor's order too. The doctor's order is written on the doctor's order form directly by the doctor or inputs the computer, the nurse can't rotate and copy duplicating. Content and initial, quiescent time of the doctor's order should be written by the doctor. The content of the doctor's order should be accurate and clear, each doctor's order should only include a content ing, and mark out and assign time, should be to minute specifically. The doctor's order can't be altered, while needing cancelling, should use red pen to mark " cancel " Sign in and words. Generally speaking, doctors can't assign the oral doctor's order. When because rescue the emergency patient to need to assign the oral doctor's order, nurses should rehearse it once. Rescue, doctor answer doctor's order of afterthought factually at once.


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