Abstract：The electronic medical record is the core of digital hospitals, and the physician order entry system is the main content of the electronic medical record system. Unstandardized medical terminologies and physician order structures have greatly restricted the construction and development of the digital hospital. This paper first pointed out the importance and effects of the physician order, analyzed its unclear and unstandardized problems in the aspects of concepts, terms, subitems, contrasts, structures as well as input. Then, corresponding solutions to the problem were put forward including complete terminologies, standardized structures, well-defined input, accurate contrasts, clear responsibilities and perfect software. Finally, the paper expounded the main benefits of standardized physician orders.
林雪金，郭志旭，陈大鹏，陈金雄. 建立受控医嘱术语实现医嘱执行全程管理[J]. 中国医疗设备, 2014, 29(2): 93-95.
LIN Xue-jin, GUO Zhi-xu, CHEN Da-peng, CHEN Jin-xiong. Establishment of the Controlled & Terminologized Physician Order for Its Whole-Process Management. China Medical Devices, 2014, 29(2): 93-95.
