Legal analysis: A special person from the medical record room regularly goes to the ward to receive the discharged medical records, which are signed by both parties. After the medical records are retrieved by a special person in the medical record room, the hospitalization number is entered in the computer on the same day to sign and register. The medical records sent back by the ward shall be sent to the medical record room for electronic signature filing by the chief resident of the department or the chief resident. After signing, the medical record room prints the handover form, which is signed by the receiver and the sender and kept by the chief resident. The medical record room is responsible for collecting medical records regularly. After receiving the phone call for medical record collection, the department doctors will send the medical records that have not been filed in time to the medical record room within 3 days. When receiving the archived medical records, the staff of the archives room have the right to reject the medical records with missing pages, missing items, incomplete filling, serious pollution and damage, and send them to the archives room on the same day after improvement by the department. First of all, we should check and ensure the integrity of 15 basic medical records, such as the first page of medical records, discharge summary, case discussion records, admission records, course records, notification consent, surgical documents, consultation sheets, nursing documents, special report stickers, imaging examination reports, laboratory tests, doctor's orders, temperature sheets, infection tables, etc., and sort them out according to the basic norms of medical record writing.

Legal basis: Article 1225 of General Principles of Civil Law of People's Republic of China (PRC), medical institutions and their medical staff should fill in and properly keep medical records such as hospitalization records, doctor's orders, inspection reports, operation and anesthesia records, pathological data and nursing records. If the patient requests to consult and copy the medical records specified in the preceding paragraph, the medical institution shall provide them in time.