【摘要】 目的了解临床护士口头医嘱执行现状及认知状况,为临床规范口头医嘱执行提供依据。方法采取自行设计的问卷,对4家二级医院、3家三级医院的755名临床护士,就执行口头医嘱的情况及对口头医嘱的认知进行调查。结果在实际临床工作中,非抢救或非手术情况下有时(1次/1～3个月)和经常(≥1次/月)执行口头医嘱的临床护士占16.9%、24.8%。本组护士均清楚执行口头医嘱的复述、确认程序,但部分护士对下达、执行口头医嘱的范围认识不全。结论临床护士对口头医嘱的认识基本正确,但在临床非抢救或非手术情况下执行口头医嘱的现象仍较多见。应加强培训,提高医护人员对执行口头医嘱的认识;加强医护协作、强化管理,以规范临床口头医嘱的执行。更多还原

【Abstract】 Objective To understand the implementation and knowledge of verbal order in clinical nurses and to provide reference for the standardization of verbal order implementation.Methods A self-designed questionnaire was applied to survey 755 clinical nurses for the implementation and knowledge of verbal order.Results Clinical nurses who implemented verbal order in the situations of non-rescue and non-operation once in one to three months and those frequently did accounted for 16.9% and 24.8% respectively.All the nurses knew the read-back and confirming of verbal order,but some of them did not know the implementation range.Conclusion Though clinical nurses present adequate knowledge of verbal order,implementation of verbal order in the situations of non-rescue and non-operation is common.Related training should be provided as well for medical staff to improve the implementation and knowledge of verbal orders.更多还原