(A) the basic rules and requirements of medical record writing
Medical record is a comprehensive record of medical staff in the medical process. 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 medical documents. The contents of medical record writing include words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities. A complete medical record is the scientific basis for diagnosis, treatment and nursing of patients. Medical records can not only objectively reflect the hospital management level and medical quality, but also be important materials for clinical teaching, scientific research and information management. At the same time, it is also the main basis for assessing the medical ethics of medical staff and evaluating the quality of medical services. Medical records are legally binding medical documents, important evidence materials for solving medical disputes, medical accidents and injury cases, and evidence for medical insurance claims. Therefore, in order to improve the quality of medical records, medical staff must write medical records objectively, truly, accurately, timely, completely and seriously with a very responsible spirit and a scientific attitude of seeking truth from facts.
Medical record writing should follow the following basic rules and requirements:
1. Medical records should be written in blue-black ink or carbon ink (unless otherwise specified), and outpatient (emergency) medical records and copying materials can be written in blue or black ballpoint pen.
2. Medical records should be written in Chinese and medical terms. Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages. The patient's previous disease name and operation name should be quoted.
3. All records in medical records must be carefully written in the prescribed format, with objective, true, accurate, timely and complete contents, focused and distinct levels; Accurate expression, concise and smooth sentences; Punctuation is correct; Clear handwriting, words do not take off the line, cross the line; No graph can be deleted or supplemented. In the process of writing, when typos and sentences appear, you should draw them with double horizontal lines, and you are not allowed to cover up or erase the original handwriting by scraping, gluing, painting and pasting.
4. The medical records written by interns, trainee medical personnel and advanced doctors shall be reviewed, revised and signed by medical personnel legally practicing in our hospital; Review and revision should keep the original records clear and identifiable; All revisions and signatures shall be made in blue-black ink or carbon ink, and the revision time shall be indicated in the lower right corner of the signature; The revision of medical records should be completed within 72 hours.
5. Outpatient medical records can be written immediately, and emergency medical records can be written in time at the same time as receiving or after disposal. Admission records should be completed within 24 hours after the patient is admitted to the hospital. Record the first course of disease within 8 hours.
6. Due to the rescue of critically ill patients, the relevant medical personnel failed to write medical records in time, and the relevant medical personnel should make up the records according to the facts within 6 hours after the rescue, and indicate the time and time of the completion of the rescue, record the patient's initial life state and the rescue process in detail, and inform the patients and their relatives of important matters and other related information.
7. All records of medical records must have a complete date and be filled in the order of "year, month and day" (for example, 2004. 1 1.27). Records of emergency and rescue should be marked with "hour and minute", and the recording time should be 24 hours, for example, noon 12.
8. Medical records should be written in accordance with the regulations, and all records should be signed in the lower right corner after writing, and the handwriting should be clear and easy to recognize. The signature of the superior doctor should be on the left side of the signing doctor, separated by a slash (/), and the modification time should be indicated in the lower right corner of the signature.
9. Medical record writing should standardize Chinese characters. Simplified Chinese characters and variant Chinese characters shall be subject to Xinhua Dictionary and shall not be invented by themselves. Put an end to typos.
10. In principle, the names of disease diagnosis, operation and various treatment operations should meet the requirements of ICD- 10 and ICD-9-CM-3. Coding must meet the specification requirements.
1 1. All forms must be filled in carefully and marked with "/"if there is no content. The lintel column of each record paper must be filled in completely (patient's name, department, ward, bed number, hospitalization number, etc.). ) and page number.
12. Anyone who is allergic to drugs should indicate the name of allergic drugs in red pen in the medical record.
13. All kinds of inspection reports should be classified and pasted neatly according to the report date order. 14. Carry out medical activities (such as special examination, special treatment, operation, experimental clinical treatment, etc.). If the patient's written consent is required according to relevant regulations, the informed consent form shall be signed by the patient himself (as evidenced by his signature or fingerprint).
When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; If the patient is unable to sign due to illness, it shall be signed by his close relatives; if there are no close relatives, it shall be signed by his related person; In order to rescue patients, if the legal representative or close relatives or related parties cannot sign in time, the person in charge of the medical institution or the authorized person in charge may sign. The signatory should indicate the relationship with the patient.
15. If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's close relatives shall be informed of the relevant situation, and the consent form shall be signed by the patient's close relatives and recorded in time. If the patient has no close relatives or the patient's close relatives are unable to sign the consent form, the patient's legal representative or relevant person shall sign the consent form and record it in time. The signatory should indicate the relationship with the patient.
(2) Format and content of outpatient (emergency) medical records 1, format and content of outpatient (emergency) medical records
The contents of outpatient (emergency) medical records include the first page of outpatient (emergency) medical records (the cover of outpatient manual), medical records, examination reports, medical images and other auxiliary examination materials, which are important materials reflecting the patient's condition and medical staff's diagnosis and treatment activities.
(1) Basic principles and requirements of medical record writing in outpatient department (emergency department)
1. The first page of outpatient (emergency) medical records should include the patient's name, gender, age, nationality, marital status, occupation, work unit, address, drug allergy history and other items, and should be carefully filled in item by item.
2. Pediatric patients, patients with disturbance of consciousness, trauma patients and mental patients must specify the name of the companion and the relationship with the patient. If necessary, indicate the work unit, address and contact telephone number of the companion.
3. Emergency patients should record blood pressure, pulse, respiration, body temperature, consciousness, treatment measures and rescue process in time. In case of death in emergency rescue, the name, professional title and position of the rescuer shall be recorded, and the time, cause and diagnosis of death shall be recorded. Patients in the emergency income observation room should write observation medical records.
4. urgent and critical patients with unknown diagnosis should arrange consultation in time, and general patients with unknown diagnosis should ask for consultation $ NUMBER times. 5. The door (emergency) medical records can be written in blue and black ink pen or ballpoint pen, and the handwriting should be clear and easy to distinguish.
6. The door (emergency) medical records written by non-practicing doctors must be approved and signed by the superior doctors.
(2) Medical records of first diagnosis in outpatient (emergency) department
1. Visiting time and department: the date (year, month and day) and visiting department of the patient should be filled in. Acute, critical and severe patients should indicate the time of seeing a doctor (year, month, day, hour and minute), and the time should be recorded in 24 hours.
2. Chief complaint: the main symptoms (signs) and their duration of this visit.
3. Medical history: The current medical history (including onset date, main symptoms, accompanying symptoms, differential diagnosis content, diagnosis and treatment in other hospitals and curative effect) should be highlighted, and the past history, personal history and family history related to this disease should be briefly described.
4. Physical examination: including the general situation and the examination of important organs, focusing on recording positive signs and negative signs that are helpful for differential diagnosis.
5 laboratory and other auxiliary inspection or consultation records.
6. Diagnosis: words such as "suspicious", "possible", "pending investigation" and "pending discharge" cannot be used. If you are not clear for the time being, you can add "?" After the name of the disease. .
7. The handling opinions shall include the following contents:
(1) branches shall record the handling methods. The name, dosage and usage of the drug shall be recorded; Need to do allergy test to indicate. (2) Further inspection measures or precautions. 8. The attending physician should sign the full name at the lower right, and draw a diagonal line on the left side of the signing physician if it needs to be reviewed by the superior physician. (3) outpatient (emergency) medical records
1. medical history: it mainly records the changes of illness and treatment response after the last diagnosis and treatment. The same symptoms and signs can be expressed as "the same medical history".
2. Physical examination: Focus on recording the changes of original positive signs and new positive signs.
3. Laboratory and other auxiliary inspection items need to be supplemented.
4. The requirements for diagnosis and treatment measures are the same as those for initial diagnosis. (4) Outpatient (emergency) clinic stays in hospital to observe the patient's medical records.
For patients who can't leave the hospital temporarily but can't stay in the hospital for various reasons, they can stay in the observation room for observation, and write down the contents that should be handled and observed in the outpatient (emergency) medical record, and if necessary, they should be handed over orally. During the observation period, if the patient's condition changes or the doctor implements a new diagnosis and treatment operation, the doctor on duty should make a detailed record in the outpatient (emergency) medical record. When patients leave the hospital after observation, they should clearly write down the treatment methods and suggestions outside the hospital on the outpatient (emergency) medical records.
When transfusion reaction, drug allergy or illness changes occur in outpatient transfusion patients, the attending doctor or the doctor on duty should deal with them in time and record them in detail in outpatient medical records.
(3) the format and content of inpatient medical records
The contents of hospitalization medical records include the first page of hospitalization medical records, admission medical records, admission records, temperature sheets, doctor's orders, course records (including rescue records), laboratory examinations, medical images and other auxiliary examination materials, as well as special examination (treatment) consent, case discussion records, consultation records, anesthesia records, surgery and anesthesia consent, surgery and surgical nursing records, nursing records, discharge records (or death records) and so on.
The writing forms of hospitalization medical records are divided into complete medical records, admission records, readmission or multiple admission records, 24-hour admission and discharge records and 24-hour admission and death records. Except that the complete medical records can be written by interns or trainee residents, and the signature of the doctors on duty with professional qualifications can be modified, other forms of hospital medical records are written by doctors on duty (or bed doctors) with professional qualifications. Admission medical records and admission records (including re-admission or multiple admission records) should be completed within 24 hours after the patient is admitted; Admission and discharge records within 24 hours should be completed within 24 hours after the patient is discharged, and admission and death records within 24 hours should be completed within 24 hours after the patient dies.
1, complete medical record
The complete medical record is the most original and detailed record of the patient after admission. It can be written by interns or trainee residents, and modified and signed by superior doctors. Its format and content are as follows:
(1) General project
General items include the patient's name, gender, age, marital status, occupation, native place, nationality, work unit and address, date of admission, reliability of medical history, and parents' names should be added to pediatrics.
The above items must be accurately recorded. Words in names cannot be replaced by homophones; Age should be stated according to the actual age, and "Cheng" and "Er" should not be used instead; 65438+ months under 0 years old and 65438+ days under 0 years old.
(2) Chief complaint
Chief complaint refers to one or several main symptoms (or signs) and their duration, nature, degree and location. ) Patients feel the most painful and obvious. Simply put, it is the "clinical manifestation" time, which is also the main reason for this patient's admission. Requirements for recording the chief complaint:
1, the chief complaint has the effect of making the finishing point. Through the accurate description of the chief complaint, doctors can often initially understand what kind of system or nature the patient is suffering from, so as to determine the diagnostic thinking of a certain disease. Therefore, writing the chief complaint must be standardized, accurate, concise, to the point, with a high degree of generality and significant intentionality. Choose the representative clinical manifestations that best reflect the nature of the disease as the main complaint, and avoid using some meaningless symptoms or signs that can't explain the problem casually.
2. The chief complaint is the procedure of the whole disease, which must closely echo the current medical history, physical examination and initial diagnosis, and the first diagnosis can be made according to the chief complaint.
3. The chief complaint consists of the most incisive words, which should be summarized in one or two sentences, generally no more than 20 words; If there is more than one chief complaint, it should be listed separately in the order of occurrence.
4. Generally, it is not appropriate to take the diagnosis name or examination results as the main complaint content, except those who are asymptomatic; Or the patient's current disease is really closely related to the disease that has been diagnosed in the past.
5. The chief complaint time should be written in Arabic numerals, such as "severe abdominal pain for 4 hours", "repeated low fever, cough for 4 months, hemoptysis for 3 days", "palpitation for 65,438+0 years after exercise, edema of lower limbs for 2 months" and so on.