应用电脑医嘱执行单 落实病历书写规范要求

Actualization of history-writing standard using execution paper of computer medical-based order

笔者介绍了利用电脑医嘱处理系统的优势对医嘱执行单的设计进行了改进,重点阐述了电脑医嘱执行单的具体内容、电脑操作程序、具体实施办法、病历保存方法,临床实践显示出明显的优越性。电脑医嘱执行单的应用,不仅落实病历书写规范要求,而且达到了省时、省力,减负增效;增强医嘱的法律效应,减少差错发生率;尊重病人权利,体现人性化关怀。

The author reported the promotion of execution paper of computer-based medical order using computer-based medical order processing system, laying stress on actual contents, operational procedure of computer, actual executive methods, storage of case history as well as its advantages in clinical practice. The application of execution paper of computer-based medical order not only actualized the requirements of history writing, but was time-saving and energy-saving. It can reinforce the legal function of case history and reduce the occurrence of mistakes. It respects the right of patients and shows humanist concerns.