网络模式下医嘱漏洞分析及查对的探讨

Approach of Analyse and Checking with the Doctor's Advice Lead under Network Pattern

目的 探讨网络模式下医嘱查对内容及查对方法。方法 随机抽查了 2 0 0 0年 8月份 96名在院病人的 2 2 38条医嘱 ,采取新旧两种不同的查对方法进行比较。结果 两种查对方法发现的医嘱漏洞及每日所用的查对时间有显著差异。医嘱漏洞的主要原因是 :医生下达医嘱不规范 ,执行医嘱前未仔细查看计价规格栏目。医嘱漏洞的项目主要是“七对”内容和计价规格栏目。漏洞查对环节 :主要是医生下达医嘱前自查 ,主班执行前首位查对。结论 网络模式下的医嘱查对重点 (1)抓住关键环节 ,缩短查对时间 ,减少人力。 (2 )规范网络下的医嘱查对内容。 (3)建立有针对性的网络查对制度 ,制定质量检查标准 ,定时评价。

Objective To approach checking content of doctor's advice and checking method under network pattern. Methods 2 238 doctor's advice of 96 patients were spot-check in 2000-08. Take two different check methods carried through compare. Results Doctor's advice leak were found by two checking methods and checking time per day had markedness difference. Mostly causation with doctor's advice leak: to issued doctor's advice were not criterion. Before the nurse administered doctor's advice were not carefully look over the price standard column. Mostly item of doctor's advice leak were content of 'seven check' and price standard column. Mostly tache with check leak: before doctor issued the doctor's advice examined self, primacy check before the nurses on duty administeried the docter's advice. Conclusion Emphases of doctor's advice leak were (1) tackle key tache, shorten checking time, reduce manpower; (2) to criterion content of check for doctor's advice; (3) to set up check system under network were provided with the pertinence, constitute quality examine criterion, timing evaluation.