The implementation of "Scoring Standard for Medical Record Writing" requires clinicians to write seriously and truthfully, which can truly reflect all records (including revisions) made by medical staff in the process of medical care. Hospital medical records and records written by rotation, further study and interns should be reviewed, revised, filed, printed and signed by teachers. It is necessary to finish the prescribed writing content in time. It can accurately reflect the medical care process of patients from admission to discharge in time series. To achieve the security required as a legal basis. All kinds of informed consent forms should be listed separately as far as possible, and both doctors and patients should sign them. Hospital medical records and various records must be signed in time. At the same time, doctors involved and attending doctors who write medical records in a perfunctory manner and blindly copy and tamper with them should be dealt with severely according to relevant regulations.