【正文】 .....................................................................................14 流程 ...............................................................................................................................14 基本流程 (圖 025) .................................................................................................14 檢查醫(yī)囑確認(rèn)收費(fèi)流程 (某些醫(yī)院使用了醫(yī)技確認(rèn)系統(tǒng) ) .........................................15 醫(yī)囑的主界面 .................................................................................................................15 長期醫(yī)囑主界面說明 (見圖 027) .............................................................................15 醫(yī)囑的各種查詢方式 .......................................................................................................17 、模板輸入方式 ......................................................................................................17 、按項(xiàng)目代碼查詢 ..................................................................................................17 、按字母查詢 .........................................................................................................17 、按項(xiàng)目中文查詢 ..................................................................................................18 用法、次數(shù)或說明的輸入方法 .........................................................................................19 各類醫(yī)囑的操作和輸入方法 ............................................................................................20 住院醫(yī)生工作站操作手冊 3 藥品醫(yī)囑的輸入 .....................................................................................................20 掌握一級(jí)護(hù)理、普食、檢查、檢驗(yàn)等非藥品醫(yī)囑的輸入 ........................................20 只需要輸入用法、次數(shù)和說明三者中的其中一個(gè)的醫(yī)囑 ........................................20 “明執(zhí) ”、 “今執(zhí)一次 ”在執(zhí)行說明中選擇 ..................................................................20 描述性醫(yī)囑的輸入 ................................................................................................21 自備藥物的輸入 .....................................................................................................21 皮試醫(yī)囑的輸入 ....................................................................................................21 在臨時(shí)醫(yī)囑中輸入大包裝藥物 ...............................................................................22 隱性組合的概念、意義以及輸入方法 .....................................................................22 在長期醫(yī)囑中開中藥醫(yī)囑 .....................................................................................23 在臨時(shí)醫(yī)囑中開中藥醫(yī)囑 (中藥處方 ).....................................................................23 術(shù)后醫(yī)囑或產(chǎn)后醫(yī)囑的輸入 .................................................................................24 停當(dāng)前行醫(yī)囑、全停醫(yī)囑、 DC 醫(yī)囑 ......................................................................25 開檢驗(yàn)醫(yī)囑以及修改和打印檢查申請單 ................................................................25 開出院帶藥及打印出院帶藥處方 ...........................................................................25 暫存和簽名的區(qū)別 ...............................................................................................26 有效和所有的區(qū)別 ...............................................................................................27 鎖定與解鎖 ..........................................................................................................27 實(shí)習(xí)、進(jìn)修、研究生、未取得執(zhí)業(yè)證的醫(yī)生開醫(yī)囑 ..............................................28 輸血項(xiàng)目前面加 ,由血庫補(bǔ)錄費(fèi)用 .....................................................................28 X 光項(xiàng)目增拍了部位，醫(yī)生需要補(bǔ)錄 醫(yī)囑 .........................................................28 其它重要說明 ......................................................................................................28 系統(tǒng)對血透室特殊流程的處理 ........................................................................................29 業(yè)務(wù)流程 .............................................................................................................29 系統(tǒng)處理 .............................................................................................................29 六、病歷操作 ..............................................................................................................................29 特殊書寫流程 .................................................................................................................29 為什么要先寫住院病歷再寫首次病程記錄？ ..........................................................29 接診醫(yī)生需要同時(shí)完成住院病歷和首次病程記錄 ....................................................29 病歷的基本操作 .............................................................................................................29 住院病歷的輸入和保存 .........................................................................................29 下診斷 ............................................................................................................................33 診斷主界面 ............................................................................................................33 診斷的輸入方法 .....................................................................................................34 書寫首次病程記錄 ...........................................................................................................36 書寫一般病程記錄 ...........................................................................................................36 掌握完成一般病程記錄的過程 ...............................................................................36 “主題”是如何使用的 .........................................................................................36 “復(fù)制”和“醫(yī)囑”按鈕的 使用 .............................................................................36 補(bǔ)寫或插入一條病程記錄 .......................................................................................36 修改病程記錄的時(shí)間時(shí)要注意的事項(xiàng) ....................................................................37 復(fù)制、粘貼其它 的病歷 ..........................................................................................37 刪除一條病程記錄 .....................................................................................