Medical orders in nursing documents are widely and importantly used in clinical settings.

When it comes to the interaction between clinicians and information systems, except for "medical record writing".

We are afraid the most common clinical scenario is "medical order issuance".

A medical order is a medical command issued by a clinician based on a patient's medical history, physical signs and test results, and is an important part of the medical process and a determinant of medical quality.

1. Types of medical orders

(1) Long-term medical orders: medical orders that are valid for more than 24 hours from the time the doctor writes them until they stop.

For example, primary care, cardiology nursing routine, low salt diet, cardioplegia 10mg, etc.

(2) Temporary medical advice: valid for less than 24 hours, should be executed within a short time, some need to be executed immediately (st), usually only once, such as 0.1% epinephrine hydrochloride H, st.

Some need to be executed within a limited time, such as consultation, surgery, examination, X-ray film, and various special examinations. In addition, discharge, transfer, death, etc. are also temporary medical orders.

(3) Standby medical orders.

①Long-term standby medical advice (prn): It means that it is valid for more than 24 hours and is used when necessary, with a time interval between executions.

And the date of cessation is indicated by the doctor before it expires. Such as pethidine 50mg, im, q6h, prn.

② Temporary standby medical advice (sos): it means that it is valid for 12 hours from the time the doctor writes the medical advice, is used when necessary and expires if it is not executed after the expiration date.

For example, Somitol 0.5g, po, sos.

2. Handling of medical prescriptions

(1) Long-term medical advice: The doctor writes long-term medical advice on the long-term medical advice sheet, indicating the date and time, and signs the full name.

The nurse will transcribe the medical advice on the long-term medical advice sheet onto various execution cards (such as medication order, injection order, treatment order, infusion order, diet order, etc.).

And the specific time of execution should be indicated and signed with the full name when transcribing.

The nurse should indicate the time of execution and sign the full name on the long-term medical order execution sheet after executing the long-term medical order.

(2) Temporary medical advice: Temporary medical advice that needs to be executed immediately should be arranged to be executed within 15 minutes.

(3) Standby medical orders.

(4) Long-term standby medical advice: nurses are handled according to long-term medical advice.

And after each execution, nurses record the execution time and sign the full name within the temporary medical order for reference on the next shift.

(5) Temporary standby medical advice: valid within 12 hours, the nurse will write the word "not used" in the column of this medical advice with a red pen if it is not executed.

(6) Stop medical advice: when stopping medical advice, the relevant items on the corresponding execution sheet should be written off.

While indicating the date and time of cessation, and after the original medical advice in the medical advice sheet, fill in the date and time of cessation, and finally sign the full name in the executioner column.

Clinically, there may be similarities in medical orders for different patients in the same scenario.

For example, all inpatients need to be issued a level of care (mostly "general care"), bed charge (mostly "general bed"), and diet (mostly "general diet").

In addition, patients in the intensive care unit may be prescribed oxygen, cardiac monitoring, the opening of intravenous access, and monitoring of intake and output.

3. Precautions

(1) Handling principles: ①Check first and then execute; ②Urgent first and then slow; ③ Temporary first and then long term; ④Full signature of the executor.

(2) Medical advice must be signed by the doctor to be valid. In general, do not implement oral medical advice.

In the course of rescue or surgery when the doctor gives oral medical advice, the executive nurse should first recite it once.

Both sides to confirm that there is no error before implementation, after the fact should be written in a timely manner.