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医嘱记录单是医师在医疗活动中下达的医学指令,医嘱记录单中存在的主要纠纷隐患问题是医嘱缺签字、代签字;医嘱未执行、未停止;医嘱与报告单不符;不规范取消;涂改、重抄。针对问题进行了分析总结,加强防范措施。
The doctor’s note is the medical order issued by the doctor in the medical activities. The main disputes in the medical records are the lack of signature and signature on the doctor’s behalf; the doctor’s advice is not executed and has not been stopped; the doctor’s advice is inconsistent with the report card; Re-read. Analyze and summarize the problems and strengthen preventive measures.