— 照護管理 · MEDIUM · SATA —
護理師接到醫師電話口頭醫囑，應採取哪些行動？（選所有適合的）
A nurse receives a phone call from a physician providing telephone prescriptions. What actions should the nurse take? (Select all that apply.)
- ARead back the orders to the physician✓ 正解向醫師覆誦醫囑
- BWrite the order directly on the medical record✓ 正解直接將醫囑記錄於病歷中
- CClarify any ambiguous medication dosage✓ 正解釐清任何模糊的藥物劑量
- DEnsure the physician signs the order within the facility's timeframe✓ 正解確保醫師在機構規定時間內簽署醫囑
- EHave another nurse witness the telephone order由另一位護理師見證電話醫囑
— Explanation · 中文詳解 —
電話醫囑程序必須嚴謹以防錯誤。標準流程為：完整記錄、覆誦確認（Read back）、釐清疑慮。寫入病歷後需由醫師在規定期限內補簽（通常 24 小時內）。非所有機構皆要求雙重簽核，故 E 非絕對必要步驟。
The nurse must document the order immediately, read it back to the physician for verification, clarify any ambiguities, and ensure the physician signs the order within the facility's required timeframe. These steps are critical for patient safety and legal compliance, while having another nurse witness the order is not universally mandated.
✦ 台美臨床差異
台灣醫院評鑑對電話醫囑要求嚴格，常需雙人核對；美國部分單位已全面導入電子病歷，極力減少電話口頭醫囑的使用。