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作为整个病历各个组成部分中最核心的部分,医嘱指的是医生根据患者的病情需要下达的书面医学指令。随着医院网络管理水平的不断提高,电子医嘱应运而生,且在临床工作中发挥着巨大的作用。不过在电子医嘱执行过程中也有出现一些医嘱遗漏执行、执行错误等问题,导致不必要的医患、护患矛盾发生。文章就电子医嘱执行中常见问题的防范措施加以探讨,旨在更好地发挥电子医嘱在临床工作中的作用,避免因电子医嘱中常见问题而发生的差错,提高医院临床工作效率。
As the core component of the entire medical record, the doctor’s advice refers to the written medical instruction that the doctor needs according to the patient’s condition. With the continuous improvement of hospital network management, electronic doctor’s orders came into being, and play a huge role in clinical work. However, during the implementation of electronic medical orders, there were also some problems such as omission of implementation of executive orders and execution mistakes, resulting in unnecessary conflicts between doctors and patients and between nurses and patients. This article discusses the preventive measures for the common problems in the execution of electronic medical orders. It aims to give better play to the role of electronic medical orders in clinical work, to avoid errors caused by common problems in electronic medical orders and to improve the clinical work efficiency in hospitals.