Legal analysis: medical record writing should follow the following basic requirements:

(1) The medical record must be written in blue-black ink pen (unless it is specified to be filled in other colors), and the content description should be written in Chinese characters (except the Latin abbreviation of measurement unit, symbol and prescription term).

(2) All records must be carefully written in accordance with the regulations, requiring complete and true contents, concise sentences, prominent points, clear levels, clear handwriting, no out-of-line words, and no arbitrary deletion or supplement.

(3) Simplified Chinese characters should be written according to the Summary of Simplified Chinese Characters published by the State Council, and shall not be fabricated to avoid typos.

(4) The names and codes of disease diagnosis and operation are written according to the International Classification of Diseases (ICD-9). Translation should be based on English-Chinese medical vocabulary published by People's Health Publishing House. Individual nouns such as disease names have not been properly translated, and their original names can be written in foreign languages. Drug names can be in Chinese, English or Latin, but chemical molecular formulas are not allowed.

(5) All records must have a complete date and be filled in the order of "year, month and day" (e.g.1991.1.27). If necessary, the time shall be marked in the form of "hour, minute, morning and afternoon" or in the form of Am, Pm, noon 12N, midnight 12MN.

(6) At the end of each record, you must sign the full name or affix the specified seal, and make it clear and easy to recognize.

(7) The unit of measurement must be the legal unit of measurement.

(8) All records written by interns, advanced doctors and residents must be reviewed by their superior doctors, modified and supplemented as necessary, and signed. All amendments and signatures should be made in red ink. Too many changes (more than 5 per page) should be copied in time.

(9) Interns, advanced doctors or junior residents (1 ~ 2 years) should write hospital medical records, and senior residents (or above) should write admission records, which should generally be completed within 24 hours after the patient is admitted to the hospital. Require critically ill patients to write the course record of their first visit in time, and complete the hospitalization medical record or admission record as soon as possible if the situation permits.

(10) On the basis of a comprehensive understanding of the illness, the superior doctor who wrote the inpatient medical record may not re-write the inpatient medical record after carefully modifying and signing the inpatient medical record to show his responsibility, but he must carefully write the first course record. The admission record written by the resident should be revised by the attending physician or above. The revision of hospital medical records or admission records by superior doctors should be completed within 72 hours at the latest.

Legal basis: the basic standard of medical record writing

Article 1 Medical records refer to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records.

Article 2 Medical record writing refers to the behavior of medical staff to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and to summarize, analyze and sort out the records of medical activities.

Article 3 The writing of medical records shall be objective, comprehensive, true, accurate, timely, complete and standardized.

Article 4 Medical records shall be written in blue-black ink and carbon ink, and copied medical records may be written in blue or black oil-water ballpoint pen. Computer printed medical records shall meet the requirements of medical record preservation.

Article 5 Medical records shall be written in Chinese, and commonly used abbreviations in foreign languages and names of symptoms, signs and diseases without official Chinese translation may be written in foreign languages.

Article 6 Medical terms shall be standardized in the writing of medical records, with neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation.

Article 7 When typos appear in the process of writing medical records, they shall be marked with double lines, and the original records shall be kept clear and readable, with the time of revision indicated and signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting. The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff.

Eighth medical records should be written in accordance with the provisions, and signed by the corresponding medical personnel. The medical records written by medical practitioners and interns shall be reviewed, revised and signed by medical personnel registered in this medical institution. Medical institutions shall, according to their own actual situation, write medical records after confirming that medical personnel are competent for their professional work.

Article 9 The date and time of medical records shall be written in Arabic numerals, and a 24-hour system shall be implemented.