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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 explore the contents of the doctor’s advice and the check-up method in the network mode. METHODS: A random sample of 962 medical doctors in hospitals in August 2000 was conducted. Two new and old methods of comparison were used to compare. RESULTS: There were significant differences between the two types of check-ups and the time spent on daily check-ups. The main reasons for the doctor’s loophole are: The doctor’s orders are not standardized, and the valuation specifications are not carefully reviewed before the doctor’s orders are executed. The items of the doctor’s loopholes are mainly the “seven pairs” content and pricing specifications. Vulnerability check: Mainly the self-examination by the doctor before the doctor’s orders, and the first check before the main class. Conclusion The focus of the doctor’s examination in the network mode (1) Seize the key links, shorten the time for investigation, and reduce manpower. (2) Regulate the contents of the doctor’s advice under the network. (3) Establish a targeted network check system, establish quality inspection standards, and make regular evaluations.