### The definition and core content of medical orders

Medical orders are written or electronic medical instructions issued by doctors based on the patient's condition and treatment needs, including specific guidance on medication, examination, treatment, care, etc. Its core structure is divided intolong-term medical advice(such as medication for chronic diseases),temporary medical orders(e.g. single inspection) andBack-up orders(such as first aid medication). The main content needs to clarify the drug name, dosage, frequency, route (such as oral/injection), treatment cycle and contraindications. The secondary content may include auxiliary information such as dietary recommendations and follow-up time. The legal validity of medical orders requires clear and traceable content, and must be signed and confirmed by a licensed physician.

Order type	Example	Implementation requirements
long-term medical advice	Metformin 500mg bid	Twice a day, continue to take
temporary medical orders	Routine blood tests	Execute immediately

### Legal and Implementation Standards for Medical Orders

According to the "Regulations on the Management of Medical Records in Medical Institutions", medical orders mustfull recordIn medical records, when modifications are made, the original records must be retained and the time of modification must be noted. The implementation link must follow the "three checks and seven pairs" principle: check medical records, check drugs, check patient identity; check name, drug name, dosage, time, route, concentration, and validity period. For example, injectable penicillin requires a skin test first. If a positive result is found, the test must be stopped immediately and a red warning must be marked. The nurse needs double signature confirmation after execution, and the electronic medical order system needs to be certified by the CA digital certificate.

key links	operating instructions	Common mistakes
Issuance link	Use standard drug names (such as generic names)	Abbreviation ambiguity (e.g. "NS" may be misinterpreted)
Transcription	two-person verification system	Dosage unit confusion (mg vs. g)

### Application of electronic medical order system

Modern hospitals commonly use electronic medical order systems (such asHIS system), reducing medication errors through intelligent reminders. The system can automatically detect drug interactions (such as the risk of combining warfarin and aspirin), allergy history (such as cross-allergy to cephalosporins and penicillins), and overdose (such as the narrow therapeutic window of digoxin). Data from Peking University People’s Hospital shows that the medication error rate in electronic medical orders has dropped by 62%. However, attention should be paid to the emergency plan in case of system crash. For example, the backup handwritten medical order book needs to be electronically added every 12 hours.

System functions	function	Typical manufacturers
Medication review	Interception of taboo compatibility	Neusoft Medical
dose calculation	Automatically converts dosage for children	Weining Health

### Medical instructions for special groups of people

Targetpregnant woman(e.g. avoid using tetracyclines),children(Calculate dosage based on body weight),People with liver and kidney dysfunction(Adjustment of drugs metabolized by the liver and kidneys), the doctor’s instructions need to specifically indicate the adjustment parameters. For example, children who use acetaminophen should be accurate to 15 mg/kg/time, and patients with renal insufficiency who use metformin need to monitor eGFR. Peking Union Medical College Hospital recommends the use ofSTART/STOPP standardEvaluate potentially inappropriate medications, such as avoiding long-acting benzodiazepines.

Special groups	Medication principles	Represents medication adjustment
Pregnancy	FDA classification B/C priority	ACEI antihypertensive drugs are prohibited
newborn	Avoid chloramphenicol gray baby syndrome	Adjustment of aminoglycosides by age

### Complete closed-loop management of medical orders

Complete medical order management includesIssue - Deliver - Execute - Record - FeedbackFive links. Mayo Clinic research shows that closed-loop management can reduce medical errors by 75%. The patient's medication instructions after discharge must include medication education (such as statins are best taken at night) and follow-up plans (such as warfarin INR monitoring). For high-risk drugs such as insulin, it is recommendedTeach-back methodConfirm patient understanding. At present, the leading medical order management systems in China include Donghua Software’s iMedical and Chuanghuang Huikang’s hospital information platform.

References:
1. "Medical Quality Management Measures" National Health Commission 2016 Edition
2. Johns Hopkins Hospital "Physician Order Management Guidelines" 2021
3. Chinese Pharmaceutical Association's "Clinical Medication Instructions" 2020 Edition