The medical record writing standards are the requirements for standardizing the writing of medical records. Medical records should be written with blue-black ink and carbon ink. Medical records that need to be copied can use blue or black oil-and-water ballpoint pens. Computer-printed medical records should meet the requirements for medical record preservation.

When a typo occurs during the writing process of the medical record, the typo should be marked with a double line, the original record should be kept clear and legible, and the time of modification should be noted and the signature of the person who modified it should be noted. It is not allowed to use scraping, sticking, painting or other methods to cover up or remove the original writing. Superior medical staff have the responsibility to review and modify medical records written by subordinate medical staff.

Additional requirements regarding medical records.

Outpatient (emergency) clinic medical records are divided into initial medical records and follow-up medical records. The written content of the initial medical record should include the time of visit, department, chief complaint, current history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions, and physician signature, etc.

The written content of the follow-up medical record should include the time of visit, department, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, treatment opinions and physician's signature, etc. Emergency medical records should specify the time of visit to the minute.