outpatient (emergency) medical records refer to the medical records formed by patients during outpatient or emergency treatment, which mainly include the following parts: first, the first page or cover of medical records contains general information of patients: name, gender, age, address, work unit, drug allergy history, etc. The second is the medical record, which is divided into the first-visit medical record and the second-visit medical record. It contains the patient's medical information, including the time of visit, department, chief complaint, current medical history, past history, signs, examination and results, diagnosis, treatment opinions and doctor's signature. Outpatient medical records should be concise and focused. Emergency medical records pay special attention to the expression of time (required to be recorded to minutes), the rescue process and consequences.
Hospitalization medical records
Hospitalization medical records refer to the comprehensive records written by doctors, nurses and other medical personnel during the hospitalization of patients. It mainly includes the following aspects: first, the first page of medical record, including general information of patients and summary of hospitalization information. The second is the hospitalization record and admission record. The hospitalization record includes the general situation, chief complaint, current medical history, past history, personal history, marriage and childbearing history, family history, menstrual history, physical examination, specialist information, auxiliary examination, preliminary diagnosis, diagnosis and treatment plan and doctor's signature; Admission record is a brief form of hospitalization record.
medical records of traditional Chinese medicine
The current medical records of traditional Chinese medicine are basically the same as those of "western medicine" mentioned above, and they are the same in terms of writing requirements, content, format, arrangement and binding order, but the medical records of traditional Chinese medicine still retain the characteristics of their information, mainly as follows: 1. Physical examination: the characteristic medical methods of "looking, smelling and cutting" and the inspection information records are retained, specifically "looking at the spirit" 2. Diagnosis: Medical records have both western medicine diagnosis and Chinese medicine diagnosis, and Chinese medicine diagnosis also includes Chinese medicine disease diagnosis and symptom diagnosis. The diagnosis of western medicine is filled in according to the disease classification code ICD-1, while the diagnosis of traditional Chinese medicine is filled in according to the Classification and Code of Diseases of Traditional Chinese Medicine (GB/T 15657—1995). To sum up, when we discuss the design of electronic medical records in the next section, it will be a challenge for Chinese medical records. First of all, we will have no foreign experience to learn from. In addition, the thinking mode and theoretical system of TCM syndrome differentiation and treatment are different from those of western medicine, and there are still many problems to be solved in the expression of knowledge, reasoning of knowledge and establishment of expert system.
There are problems with paper medical records. Paper medical records have the following essential problems in storing and utilizing medical information: 1. The exclusivity of information; 2. The vulnerability of information; 3. The uncertainty of information; 4. The passivity of information utilization; 5. The obstacles of information reuse.