Basic Standards for Writing Medical Records

Chapter 1 Basic Requirements

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

Article 2 Medical record writing refers to medical personnel obtaining relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment, and nursing, and summarizing, analyzing, and organizing to form medical activity records. Behavior.

Article 3 Medical record writing should be objective, true, accurate, timely and complete.

Article 4: Blue-black ink and carbon ink should be used to write inpatient medical records. Blue or black oil-water ballpoint pens can be used for outpatient (emergency) medical records and materials that need to be copied.

Article 5: Medical records should be written in Chinese and medical terminology. Common foreign abbreviations and symptoms, signs, disease names, etc. that do not have official Chinese translations can be used in foreign languages.

Article 6 Medical records should be written neatly, with clear handwriting, accurate expressions, smooth sentences and correct punctuation. When a typo occurs during writing, double lines should be used to mark the typo, and methods such as scraping, gluing, and coating are not allowed to cover up or remove the original handwriting.

Article 7 Medical records shall be written in accordance with the prescribed contents and signed by the corresponding medical staff. Medical records written by intern medical personnel and probationary medical personnel shall be reviewed, modified and signed by medical personnel legally practicing in the medical institution. Medical personnel undergoing further training should be identified by the medical institution accepting the training based on their actual qualifications for the professional work and then write medical records.

Article 8: Superior medical personnel have the responsibility to review and modify medical records written by subordinate medical personnel. When making modifications, the date of modification should be indicated, the signature of the person making the modification should be noted, and the original record should be kept clear and legible.

Article 9: If the medical record is not written in time due to rescuing an emergency patient, the relevant medical personnel shall make up the actual record within 6 hours after the end of the rescue and make an annotation.

Article 10: For medical activities that require the written consent of the patient in accordance with relevant regulations (such as special examinations, special treatments, surgeries, experimental clinical treatments, etc.), the patient shall sign a consent form. When the patient does not have full capacity for civil conduct, his or her legal representative shall sign; when the patient is unable to sign due to illness, his or her close relatives shall sign; if there are no close relatives, his or her related persons shall sign; in order to rescue the patient, the legal representative shall sign Or if close relatives or related persons are unable to sign in time, the person in charge of the medical institution or the authorized person in charge may sign.

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 should be notified of the relevant situation, and the patient’s close relatives should sign a consent form and record it in a timely manner. If the patient has no close relatives or if the patient's close relatives are unable to sign the consent form, the patient's legal representative or related person shall sign the consent form.

Chapter 2 Requirements and Contents for Outpatient (Emergency) Clinic Medical Records

Article 11 The contents of outpatient (emergency) clinic medical records include the first page of outpatient medical records (cover of outpatient clinic manual), medical record records , laboratory test orders (test reports), medical imaging examination data, etc.

Article 12 The home page of outpatient (emergency) medical records shall include the patient’s name, gender, date of birth, ethnicity, marital status, occupation, work unit, address, drug allergy history and other items. The cover content of the outpatient manual should include the patient's name, gender, age, work unit or address, medication

Allergy history and other items.

Article 13: 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, physician signature, etc. The written content of follow-up medical records 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. The time of consultation should be written down to the minute in the emergency medical record.

Article 14: Outpatient (emergency) medical records shall be completed by the attending physician in a timely manner when the patient is treated.

Article 15: When rescuing critically ill patients, rescue records must be written. For patients admitted to the emergency observation room, observation records during their stay should be written.

Chapter 3 Requirements and Contents for Writing Inpatient Medical Records

Article 16 The contents of inpatient medical records include the home page of the inpatient medical record, hospitalization notes, body temperature sheets, medical orders, and laboratory test orders (test reports) , medical imaging examination data, special examination (treatment) consent form, surgery consent form, anesthesia record sheet, surgery and surgical nursing record sheet, pathology data, nursing records, discharge records (or death records), disease course records (including rescue records) , discussion records of difficult cases, consultation opinions, ward rounds records of superior doctors, discussion records of death cases, etc.

Article 17: Hospital records refer to records written by treating physicians who obtain relevant information through consultation, physical examination, and auxiliary examination after the patient is admitted to the hospital, and summarize and analyze the information. The writing form of hospitalization records is divided into admission records, re- or multiple admission records, admission and discharge records within 24 hours, and admission death records within 24 hours. Admission records, re- or multiple admission records should be completed within 24 hours after the patient is admitted;

2 Basic standards for writing medical records

Discharge records should be entered within 24 hours after the patient is discharged be completed within 24 hours, and the record of admission deaths within 24 hours should be completed within 24 hours after the patient's death.

Article 18 Requirements and contents of admission records.

(1) The patient’s general information includes name, gender, age, ethnicity, marital status, place of birth, occupation, date of admission, date of recording, and person stating the medical history.

(2) Chief complaint refers to the main symptoms (or signs) and duration that prompt the patient to seek medical treatment.

(3) The medical history of the current illness refers to the patient’s detailed information on the occurrence, evolution, diagnosis and treatment of the disease, and should be written in chronological order. The content includes the incidence, main symptom characteristics and their development and changes, accompanying symptoms, diagnosis and treatment process and results after the onset, changes in general conditions such as sleep and diet, as well as positive or negative data related to differential diagnosis, etc. Other diseases that are not closely related to the current disease but still require treatment can be recorded in a separate paragraph after the current history.

(4) Past history refers to the patient’s past health and disease conditions. The content includes past general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, drug allergy history, etc.

(5) Personal history, marriage and childbearing history, menstrual history of female patients, and family history.

(6) The physical examination should be written in a systematic order. Content includes body temperature, pulse, respiration, blood pressure, general condition, skin, mucous membranes, superficial lymph nodes throughout the body, head and its organs, neck, chest (thoracic cage, lungs, heart, blood vessels), abdomen (liver, spleen, etc.) , rectum and anus, external genitalia, spine, limbs, nervous system, etc.

(7) Special circumstances of specialty The special circumstances of the specialty should be recorded according to the needs of the specialty.

(8) Auxiliary examination refers to the main examination related to the disease and its results performed before admission. The date of the examination should be stated. If the examination was performed at another medical institution, the name of the institution should be stated.

(9) Preliminary diagnosis refers to the diagnosis made by the treating physician based on a comprehensive analysis of the patient's condition at the time of admission. If the initial diagnosis is multiple, the priority should be clearly defined.

(10) The signature of the physician writing the admission record.

Article 19 Records of readmissions or multiple admissions refer to records written when patients are admitted to the same medical institution again or multiple times due to the same disease. The requirements and content are basically the same as the admission record, with the following characteristics: the chief complaint is to record the main symptoms (or signs) and duration of the patient's admission; the history of current illness requires a summary of the previous hospitalization diagnoses and treatments before the current hospitalization, and then Write down the history of current illness for this admission.

Article 20 If a patient is discharged within 24 hours of admission, a record of admission and discharge within 24 hours can be written.

The content includes the patient's name, gender, age, occupation, admission time, discharge time, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, discharge status, discharge diagnosis, discharge medical order, physician's signature, etc.

Article 21 If a patient dies within 24 hours of admission, a death record of admission within 24 hours can be written. The content includes the patient's name, gender, age, occupation, time of admission, time of death, chief complaint, admission status, admission diagnosis, diagnosis and treatment process (rescue process), cause of death, death diagnosis, physician's signature, etc.

Article 22: Disease course records refer to the continuous records of the patient’s condition and diagnosis and treatment process following the inpatient diary. The content includes changes in the patient's condition, important auxiliary examination results and clinical significance, superior doctors' ward round opinions, consultation opinions, doctors' analysis and discussion opinions, diagnostic and treatment measures taken and their effects, changes in medical orders and reasons, and information to patients and their close relatives. Important matters to be notified, etc.

Article 23: Requirements and contents of disease course records.

(1) The first course of illness record refers to the first course of illness record written by the treating physician or the physician on duty after the patient is admitted to the hospital, and should be completed within 8 hours of the patient's admission. The content of the first disease course record includes case characteristics, diagnostic basis, differential diagnosis, diagnosis and treatment plan, etc.

(2) Daily course records refer to regular and continuous records of the diagnosis and treatment process of patients during their hospitalization. It can be written by a doctor, or by a trainee medical staff or a probationary medical staff. When writing daily disease course records, first indicate the date of recording and record the specific content on a separate line. Critically ill patients should write a record of their disease course at any time according to changes in their condition, at least once a day, and the recording time should be specific to the minute. For seriously ill patients, the course of the disease should be recorded at least once every 2 days. For patients whose condition is stable, the course of the disease should be recorded at least once every 3 days. For patients with chronic diseases whose condition is stable, the course of the disease should be recorded at least once every 5 days.

(3) The superior physician’s ward round records refer to the superior physician’s records of the patient’s condition, diagnosis, differential diagnosis, analysis of the efficacy of current treatment measures, and opinions on the next step of diagnosis and treatment during the ward rounds.

The attending physician’s first ward round record should be completed within 48 hours of the patient’s admission. The content includes the name of the ward rounds physician, professional and technical positions, supplementary medical history and physical signs, analysis of diagnostic basis and differential diagnosis, and diagnosis and treatment plan, etc. The attending physician's daily ward rounds record interval is determined based on the condition and diagnosis and treatment. The content includes the name of the ward rounds physician, professional and technical position, analysis of the condition, diagnosis and treatment opinions, etc. Records of ward rounds by the department director or a physician with professional and technical qualifications of deputy chief physician or above, including the name of the ward-rounding physician, professional and technical position, analysis of the condition, and diagnosis and treatment opinions, etc.

3 Basic Standards for Writing Medical Records

(4) Difficult case discussion records refer to meetings chaired by the department director or a physician with professional and technical qualifications of deputy chief physician or above, convening relevant medical personnel to discuss Records of discussions of cases where diagnosis is difficult or treatment is uncertain. The content includes the date of discussion, names of moderators and participants, professional and technical positions, discussion opinions, etc.

(5) Handover (succession) records refer to records in which the switching physician and the succeeding physician respectively briefly summarize the patient's condition and diagnosis and treatment when the patient's treating physician changes. The shift handover record should be written and completed by the changing physician before the shift is handed over; the shift handover record should be completed by the succeeding physician within 24 hours after taking over.

The content of the handover (succession) record includes the date of admission, date of handover or succession, patient name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, handover precautions or succession diagnosis and treatment plan, physician Signature etc.

(6) Transfer records refer to records written by the doctors of the transferring department and the transferring department respectively when a patient needs to be transferred to another department during his hospitalization, after consultation with the transferring department doctor and consent to accept the patient. Includes transfer-out records and transfer-in records. The transfer-out record shall be written by the physician of the transferring department before the patient is transferred out of the department (except in emergencies); the transfer-in record shall be completed by the physician of the transferring department within 24 hours after the patient is transferred in.

The transfer records include the date of admission, date of transfer out or in, patient name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, transfer subjects and precautions or transfer diagnosis and treatment plan , physician signature, etc.

(7) Stage summary refers to a monthly summary of the patient's condition, diagnosis and treatment made by the treating physician when the patient has been hospitalized for a long time. The contents of the stage summary include admission date, summary date, patient name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, physician signature, etc.

Class handover (takeover) records and department transfer records can replace the stage summary.

(8) Rescue record refers to the record made when the patient is in critical condition and rescue measures are taken. The content includes changes in the condition, rescue time and measures, names and professional and technical positions of medical personnel participating in the rescue, etc. The rescue time should be recorded down to the minute.

(9) Consultation records (including consultation opinions) refer to the records written by the applicant physician and the consulting physician respectively when the patient requires assistance from other departments or other medical institutions for diagnosis and treatment during hospitalization. The content includes application consultation records and consultation opinion records. The record of application for consultation should briefly state the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and the signature of the physician applying for consultation, etc. Records of consultation opinions

There should be consultation opinions, the department where the consulting physician works or the name of the medical institution, the time of consultation, and the signature of the consulting physician, etc.

(10) Preoperative summary refers to the summary of the patient's condition made by the treating physician before surgery. The content includes brief medical condition, preoperative diagnosis, surgical indications, name and method of the proposed operation, proposed anesthesia method, precautions, etc.

(11) Preoperative discussion record refers to the discussion and response to the proposed surgical method and possible problems that may arise during the operation under the auspices of the superior physician before the operation due to the serious condition of the patient or the difficulty of the operation. discussion of measures. The content includes preoperative preparations, surgical indications, surgical plans, possible accidents and preventive measures, names of participants in the discussion, professional and technical positions, discussion date, signature of the recorder, etc. o

(十2) Anesthesia records refer to the records of the anesthesia process and treatment measures written by the anesthesiologist during the implementation of anesthesia. The anesthesia record should be written on a separate page, including the patient's general condition, pre-anesthesia medication, pre-operative diagnosis, intra-operative diagnosis, anesthesia method, medication and treatment during anesthesia, operation start and end time, signature of the anesthesiologist, etc.

(13) Operation records refer to special records written by the operator that reflect the general conditions of the operation, the operation process, intraoperative findings and treatment, etc., and should be completed within 24 hours after operation. In special circumstances, when written by the first assistant, it should be signed by the surgeon. The surgical record should be written on a separate page, including general items (patient name, gender, department, ward, bed number, hospitalization record number or case number), date of surgery, preoperative diagnosis, intraoperative diagnosis, name of the surgery, operator and Assistant’s name, anesthesia method, operation process, intraoperative conditions and treatment, etc.

(14) Surgical nursing records refer to the roving nurse’s records of the intraoperative care of surgical patients and the instruments and dressings used, which should be completed immediately after the operation. The surgical nursing record should be written on a separate page, including the patient's name, hospitalization record number (or medical record number), date of surgery, name of the surgery, intraoperative care, and inventory and verification of the number of various instruments and dressings used. Signatures of circulating nurses and surgical instrument nurses, etc.

4 Basic specifications for writing medical records

(15) The first post-operative course record refers to the record of the course of illness completed by the physician participating in the operation immediately after the patient's surgery. The content includes operation time, intraoperative diagnosis, anesthesia method, surgical method, brief operation process, postoperative treatment measures, matters that should be paid special attention to after operation, etc.

Article 24 A consent form for surgery refers to a medical document in which the treating physician informs the patient of the relevant circumstances of the proposed surgery before surgery, and the patient signs and agrees to the surgery. The content includes preoperative diagnosis, name of the operation, possible complications during or after the operation, surgical risks, patient signature, physician signature, etc.

Article 25 The consent form for special examinations and special treatments means that before special examinations and special treatments are carried out, the treating physician informs the patient of the relevant circumstances of the special examination and special treatment, and the patient signs and agrees. Medical documents for examination and treatment. The content includes special examinations, names and purposes of special treatment items, possible complications and risks, patient signatures, physician signatures, etc.

Article 26 The discharge record refers to the treating physician’s summary of the patient’s diagnosis and treatment during the hospitalization, which should be completed within 24 hours after the patient is discharged. The content mainly includes admission date, discharge date, admission status, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge status, discharge medical order, physician signature, etc.

Article 27 Death record refers to the treating physician’s record of the diagnosis, treatment and rescue process of the deceased patient during his hospitalization, which should be completed within 24 hours after the patient’s death. The content includes the date of admission, time of death, admission status, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of the condition and the rescue process), cause of death, death diagnosis, etc. Time of death should be recorded down to the minute.

Article 28 Death case discussion records refer to the discussion and analysis of death cases hosted by the department director or a physician with professional and technical qualifications above deputy chief physician within one week of the patient’s death. Record. The content includes the date of discussion, names of moderators and participants, professional and technical positions, discussion opinions, etc.

Article 29 Medical orders refer to medical instructions issued by doctors in medical activities. The content of the medical order and the start and stop times should be written by the physician.

The contents of medical orders should be accurate and clear. Each medical order should contain only one content and indicate the time of issuance, which should be specific to the minute.

Doctor’s orders may not be altered. When cancellation is required, the word "Cancel" should be marked in red ink and signed.

Under normal circumstances, physicians are not allowed to issue oral medical orders. When oral medical orders need to be given to rescue critical patients, the nurse should repeat them. After the rescue, the doctor should immediately make up the medical instructions according to the facts.

Medical orders are divided into long-term medical orders and temporary medical orders. The content of the long-term medical order includes the patient's name, department, hospitalization record number (or medical record number), page number, start date and time, content of the long-term medical order, stop date and time, physician's signature, execution time, and execution nurse's signature. The content of the temporary medical order includes the time of the medical order, the content of the temporary medical order, the physician's signature, the execution time, the execution nurse's signature, etc.

Article 30 The auxiliary examination report sheet refers to the record of various tests and examination results performed during the patient's hospitalization. The content includes the patient's name, gender, age, hospitalization record number (or medical record number), examination items, examination results, report date, signature or seal of the reporting person, etc.

Article 31 The temperature sheet is in table format and is mainly filled in by nurses. The content includes the patient's name, department, bed number, admission date, hospitalization record number (or medical record number), date, days after surgery, body temperature, pulse, respiration, blood pressure, stool frequency, fluid intake and output, weight, weeks of hospitalization, etc. .

Article 32 Nursing records are divided into general patient nursing records and critical patient nursing records.

General patient care records refer to nurses’ objective records of the care process of general patients during their hospitalization based on doctor’s orders and conditions. The content includes patient name, department, hospitalization record number (or medical record number), bed number, page number, record date and time, condition observation, nursing measures and effects, nurse signature, etc. Critical patient care records refer to nurses’ objective records of the nursing process of critically ill patients during their hospitalization based on doctor’s orders and conditions. Nursing records for critically ill patients should be written according to the nursing characteristics of the corresponding specialty. The content includes the patient’s name, department, hospitalization record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other condition observations, nursing measures and effects, nurse signature, etc. . Recording times should be specified to the minute.

Chapter 4 Others

Article 33 The first page of inpatient medical records shall be in accordance with the "Notice of the Ministry of Health on Revising and Issuing the First Page of Inpatient Medical Records" (Weiyifa [2001] No. 286 ).

The meaning of Article 34 special examination and special treatment shall be in accordance with Article 88 of the "Implementation Rules of the Medical Institution Management Regulations" No. 35 of the Ministry of Health on August 29, 1994.

Article 35 The basic standards for writing medical records of traditional Chinese medicine will be formulated separately.

Article 36 This specification will come into effect on September 1, 2002.