The medical record writing requirements are that the medical records must be objective, true, accurate, timely, complete and standardized.

1. Medical records must be written with blue and black ink pens (except for those designated to be filled in with pens of other colors), and content descriptions must be in Chinese characters (except for measurement units, symbols, and Latin abbreviations of prescription terms, etc.).

2. All records must be carefully written in accordance with regulations. The content is required to be complete and true, the sentences are concise, the key points are clear, the writing is clear, the words are not out of line or across lines, and no deletions or additions are allowed at will.

3. Simplified characters should be written in accordance with the provisions of the "General List of Simplified Characters" published by the State Council, and must not be fabricated to avoid typos.

4. Disease diagnosis and operation name coding are written in accordance with the International Classification of Diseases (ICD-9). The translated name should be based on the "English-Chinese Medical Glossary" published by People's Medical Publishing House; if there is no appropriate translation for individual nouns such as disease names, the original foreign names can be written. Drug names can be in Chinese, English or Latin, but chemical formulas are not allowed.

5. Each record must have a complete date, filled in in the order of "year, month, day" (such as 1991.11.27). If necessary, the time should be added, written in the format of "hours and minutes/morning, afternoon", or Am represents morning, Pm represents afternoon, 12 o'clock at noon is 12N, and 12 o'clock at midnight is 12MN.

6. At the end of each record, your full name must be signed or the prescribed seal must be stamped, and it must be clear and easy to read.

7. The measurement unit must use legal measurement units.

8. All records written by interns, visiting physicians and residents must be reviewed by their superior physicians, and necessary modifications and additions must be made and signed. All modifications and signatures should be made in red ink. If there are too many revisions (more than 5 places per page), you should copy it again in time.