(1) The cover content of outpatient medical records should be carefully filled in item by item. Fill in the patient's name, gender, age, work unit or address, outpatient number and public (self) fee from the registration room. X-ray number, electrocardiogram and other special inspection numbers, drug allergy, hospitalization number, etc. It should be filled out by a doctor.

(2) The medical records of newly diagnosed patients should include "five signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and doctor's signature). Among them: ① Medical history should include present medical history, past medical history, personal history related to the disease, marriage, menstruation, birth history, family history, etc. ② Physical examination should record the main positive bodies and negative signs with differential diagnosis significance. (3) List the names of diseases that are initially diagnosed or most likely, and try to avoid using words such as "to be investigated" and "to be diagnosed". (4) The treatment opinions should list the drugs used and special treatment methods, further examination items, matters needing attention in life, rest methods and time limit; If necessary, record the appointment date and follow-up requirements.

(3) Patients who return to the clinic should focus on the diagnosis and treatment results and the evolution of the disease after the previous return visit; Physical examination can focus on the last positive discovery and the newly discovered signs; Supplementary necessary auxiliary inspection and special inspection. For patients who cannot be diagnosed for three times, the attending doctor should ask the superior doctor for consultation. For diseases different from last time, all outpatient medical records should be written according to newly diagnosed patients.

(4) The date of each visit should be filled in, and the specific time should be filled in for emergency patients.

(5) When consulting in other departments, the purpose, requirements and preliminary opinions of the undergraduate course should be clearly filled in the medical records, and signed by senior doctors in our hospital.

(6) Invited consultants (senior doctors in our hospital) should fill in the examination results, diagnosis and treatment opinions on the consultation medical records for instructions.

(7) When outpatients need hospitalization examination and treatment, doctors should fill in the hospitalization certificate.

(8) The outpatient physician is responsible for filling in the medical record summary for the referred patients.

(9) The epidemic situation report shall be indicated for legal infectious diseases.

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