Rijal A, Gautam K, Rijal A S
Department of Surgery, Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal.
Nepal Med Coll J. 2011 Dec;13(4):267-71.
A medical order is a medical and legal document and careful writing of this document is necessary. In Nepal the medical order in the admitted patients is written on a cardex which is utilised by the nurses to dispense medicines and to follow the doctor's orders. However, with the dawn of the electronic age this is being replaced by a computerized system, which is suggested to be better. The aim of this study was to identify if the existing cardex was adequate for the purpose of writing orders, or whether this needed modification. This was a prospective observational study were 240 cardexes from eight different Departments from the same Medical College Hospital were randomly looked into for errors. Thirteen different parameters were looked into including the legibility/readability of the handwriting. The results suggested the error rates to be high in certain parameters viz. utilization of the columns (77.9%), documentation of allergy history (77.5%), writing the prescribers name (89.6%) and writing date of discontinuation of medicines (62.5%). The handwriting was unreadable or difficult to read in 49.2% of the documents. However, the other parameters also had errors and no parameter was error free. The study suggested the need of the hour was to modify the existing cardex and also to educate the doctors to minimise errors. However, in the future we may have to move towards a computerized system in order to avoid errors related to bad handwriting.
医嘱是一份医疗和法律文件，认真书写这份文件很有必要。在尼泊尔，住院患者的医嘱写在病历卡上，护士据此配药并执行医生的医嘱。然而，随着电子时代的到来，这正被一个计算机系统所取代，人们认为这个系统更好。本研究的目的是确定现有的病历卡是否足以用于书写医嘱，或者是否需要修改。这是一项前瞻性观察研究，从同一医学院附属医院的八个不同科室随机抽取了240份病历卡，检查其中的错误。研究考察了13个不同参数，包括字迹的清晰度/可读性。结果表明，某些参数的错误率较高，即：栏目使用情况（77.9%）、过敏史记录（77.5%）、开处方者姓名书写（89.6%）以及停药日期书写（62.5%）。49.2%的文件字迹难以辨认或很难读懂。然而，其他参数也存在错误，没有一个参数是完全没有错误的。该研究表明，当务之急是修改现有的病历卡，并对医生进行培训以尽量减少错误。不过，未来我们可能不得不转向计算机系统，以避免因字迹潦草而产生的错误。
