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, 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.
Tenth medical activities that require the written consent of patients shall be signed by the patients themselves. When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; When the patient is unable to sign due to illness, it shall be signed by the person authorized by him; In order to rescue patients, if the legal representative or the authorized person cannot sign in time, the person in charge of the medical institution or the authorized person may sign.
If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, it shall inform the patient's close relatives, and the informed 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 consent form shall be signed by the patient's legal representative or relevant person. Article 11 The contents of outpatient (emergency) medical records include the first page of outpatient (emergency) medical records (the cover of outpatient (emergency) medical manual), medical records, laboratory tests (inspection reports), medical imaging examination materials, etc.
Twelfth outpatient (emergency) medical records should include the patient's name, gender, date of birth, nationality, marital status, occupation, work unit, address, drug allergy history and other items.
The cover content of outpatient manual should include the patient's name, gender, age, work unit or address, drug allergy history and other items.
Thirteenth outpatient (emergency) medical records are divided into initial medical records and follow-up medical records.
The contents of the first medical record should include the time of seeing a doctor, the patient, chief complaint, current medical history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions and doctor's signature, etc.
The contents of the follow-up medical record should include the time of visit, the patient, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, treatment and treatment opinions, and doctor's signature.
The writing time of emergency medical records should be specific to minutes.
Fourteenth outpatient (emergency) medical records should be filled in by the attending physician in time when the patient is hospitalized.
Fifteenth emergency observation records are records of emergency patients who need to stay in hospital for observation because of their illness, focusing on the changes of their illness and the measures of diagnosis and treatment during the observation period. The records are concise and to the point, indicating the whereabouts of the patients. When rescuing critically ill patients, rescue records should be written. The writing contents and requirements of emergency outpatient medical records refer to the writing contents and requirements of inpatient medical records. Article 16 The contents of hospital medical records include the first page of hospital medical records, admission records, course records, operation consent, anesthesia consent, informed consent of blood transfusion treatment, consent of special examination (special treatment), notice of critical illness (severe illness), doctor's advice, auxiliary examination report, temperature list, medical imaging examination data and pathological data.
Seventeenth admission records refer to the records written by the attending physician, obtained through consultation, physical examination and auxiliary examination, and summarized and analyzed. It can be divided into admission records, readmission records or multiple admission records, admission and discharge records within 24 hours, admission and death records within 24 hours.
Admission records and readmission records should be completed within 24 hours after the patient is admitted to the hospital; 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.
Article 18 Requirements and contents of admission records.
(1) The general information of patients includes name, gender, age, nationality, marital status, birthplace, occupation, admission time, recording time and medical history statement.
(2) Chief complaint refers to the main symptoms (or signs) of patients and the duration of treatment.
(three) the current medical history refers to the details of the occurrence, evolution, diagnosis and treatment of the patient's disease, which should be written in chronological order. The contents include the incidence, the characteristics and development of main symptoms, accompanying symptoms, the course of disease and the results of diagnosis and treatment after onset, changes in general conditions such as sleep and diet, and positive or negative data related to differential diagnosis.
1. Incidence: record the time, place, priority of onset, precursor symptoms, possible causes or incentives.
2. Characteristics and development of main symptoms: describe the location, nature, duration, degree, relieving or aggravating factors, evolution and development of main symptoms in order of occurrence.
3. Accompanying symptoms: record accompanying symptoms and describe the relationship between accompanying symptoms and main symptoms.
4. Diagnosis and treatment process and results since the onset: record the detailed process and effect of examination and treatment in and out of the hospital from the onset to admission. Names of drugs, diagnosis and operation provided to patients should be marked with quotation marks ("") to distinguish them.
5. General situation since the onset: briefly record the patient's mental state, sleep, appetite, defecation and weight after the onset.
Other diseases that are not closely related to this disease but still need treatment can be recorded in another paragraph after the current medical history.
(4) Past history refers to the patient's past health and illness. The contents include general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, food or drug allergy history, etc.
(5) Personal history, marriage and childbearing history, menstrual history and family history.
1. Personal history: record the birthplace and long-term residence, living habits, hobbies such as alcohol, tobacco and drugs, occupation and working conditions, contact history of industrial poisons, dust and radioactive substances, smelting and travel history.
2. Marriage and childbearing history, menstrual history: marital status, marriage age, spouse's health status, children, etc. Female patients recorded menarche age, menstrual period days, interval days, last menstruation (or amenorrhea age), menstrual flow, dysmenorrhea and delivery.
3. Family history: the health status of parents, brothers and sisters, whether there are diseases similar to the patients, and whether there are diseases with family genetic tendency.
(6) Physical examination writing should be systematic and orderly. The contents include temperature, pulse, respiration, blood pressure, general condition, skin, mucosa, superficial lymph nodes, head and its organs, neck, chest (chest, lung, heart, blood vessels), abdomen (liver, spleen, etc. ), rectum and anus, external genitalia, spine, limbs, nervous system, etc.
(seven) the special circumstances of the profession should be recorded according to the needs of the profession.
(eight) auxiliary examination refers to the main examination and its results related to this disease before admission. Inspection results shall be recorded in the order of inspection time. For inspection in other medical institutions, the name and inspection number of the institution shall be stated.
(9) Preliminary diagnosis refers to the diagnosis made by the attending physician according to the comprehensive analysis of the patient when he is admitted to the hospital. If the initial diagnosis is multiple, the priority should be clear. Cases to be investigated should list more likely diagnoses.
(ten) the signature of the doctor who wrote the admission record.
Nineteenth readmission records refer to the records written by patients who have stayed in the same medical institution for the same disease or many times. The requirements and contents are basically the same as the admission records. The chief complaint is to record the main symptoms (or signs) and duration of the patient's admission; In the current medical history, it is required to summarize the previous hospitalization experience before this hospitalization, and then write the current medical history of this hospitalization.
Twentieth patients who are discharged less than 24 hours after admission can write the admission and discharge records within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, discharge time, chief complaint, admission, admission diagnosis, diagnosis and treatment process, discharge, discharge diagnosis, discharge doctor's order, doctor's signature, etc.
Twenty-first patients who died less than 24 hours after admission can write death records within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, death time, chief complaint, admission situation, admission diagnosis, diagnosis and treatment process (rescue process), cause of death, death diagnosis, doctor's signature, etc.
Twenty-second course record refers to the continuous record of the patient's condition and diagnosis and treatment process after admission record. The contents include the patient's condition change, important auxiliary examination results and clinical significance, superior doctors' rounds, consultation opinions, doctors' analysis and discussion opinions, diagnosis and treatment measures and effects, changes and reasons of doctor's orders, important matters that need to be informed to patients and their close relatives, etc.
Requirements and contents of course records:
(a) the first course record refers to the first course record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first diagnosis record include the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), the diagnosis and treatment plan, etc.
1. Case characteristics: The characteristics of this case should be written after comprehensive analysis, induction, collation of medical history, physical examination and auxiliary examination, including positive findings and negative symptoms and signs with differential diagnosis significance.
2. Quasi-diagnosis discussion (diagnosis basis and differential diagnosis): according to the characteristics of the case, put forward the preliminary diagnosis and diagnosis basis; Write differential diagnosis and analyze unknown diagnosis; And analyze the next diagnosis and treatment measures.
3. Diagnosis and treatment plan: put forward specific examination and treatment measures.
(two) the daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by the attending physician, but also by the internship or trainee medical staff, but should be signed by the attending physician. When writing the daily course record, first indicate the recording time, and write another line for the specific content. For critically ill patients, the course of the disease should be recorded at any time according to the change of the condition, at least/kloc-0 times a day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days.
(3) The records of superior doctors' rounds refer to the records of patients' condition, diagnosis, differential diagnosis, curative effect analysis of current treatment measures and opinions on the next diagnosis and treatment.
The attending physician's first round of rounds should be completed within 48 hours after the patient is admitted to the hospital. The contents include name, professional and technical position, supplementary medical history and signs, diagnosis basis, differential diagnosis and treatment plan, etc.
The time interval of the attending physician's daily rounds is determined according to the condition and diagnosis and treatment, including the name of the attending physician, professional and technical positions, condition analysis and diagnosis and treatment opinions.
The records of ward rounds of doctors with professional and technical positions or above, including the names of ward rounds doctors, professional and technical positions, illness analysis, diagnosis and treatment opinions, etc.
(4) The discussion record of difficult cases refers to the record presided over by the director of the department or a physician with professional and technical qualifications above the deputy chief physician, and convened relevant medical personnel to discuss cases with difficult diagnosis or uncertain curative effect. The contents include the date of discussion, the moderator, the names and professional and technical positions of the participants, the specific discussion opinions and the moderator's summary opinions.
(5) The shift (pick-up) record refers to the record that the shift doctor and the succession doctor briefly summarize the patient's condition and diagnosis and treatment respectively when the patient's attending doctor changes. The log record shall be filled in by the log doctor before the log; The shift record shall be completed by the shift doctor within 24 hours after the shift. The contents of the handover record include admission date, handover or handover, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in handover or handover diagnosis and treatment scheme, and doctor's signature, etc.
(6) The record of changing majors refers to the records written by the doctors in the transfer-out department and the transfer-in department respectively after the patient needs to change majors during hospitalization and agrees to receive them. Include a transfer-out record and a transfer-in record. The transfer-out record is written by the doctor in the transfer-out department before the patient is transferred out of the department (except for emergency); The transfer-in record should be completed by the doctor in the transfer-in department within 24 hours after the patient is transferred. The record of changing major includes admission date, transfer-out or transfer-in date, transfer-out and transfer-in department, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in changing major or transferring to diagnosis and treatment scheme, and doctor's signature.
(seven) stage summary refers to the patient's hospitalization time is longer, and the monthly summary of the condition and diagnosis and treatment made by the attending physician. The contents of the stage summary include admission date, summary date, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, doctor's signature, etc.
Changes in handover (pick-up) records and main records can replace stage summary.
(eight) the rescue record refers to the record made when the patient is in critical condition and takes rescue measures. If the medical records cannot be written in time due to the rescue of critically ill patients, the relevant medical personnel shall make up the facts within 6 hours after the rescue and make records. The contents include the change of illness, the time and measures of rescue, the names and titles of medical personnel involved in rescue, etc. Record the rescue time to the minute.
(9) Invasive diagnosis and treatment operation records refer to records of various diagnosis and treatment operations (such as thoracic puncture and abdominal puncture, etc.). ) in the process of clinical diagnosis and treatment. You should write immediately after the operation is completed. The contents include the name of the operation, the operation time, the operation steps, the results and the general situation of the patient, whether the recording process is smooth, whether there are any adverse reactions, matters needing attention after the operation, whether to explain to the patient, and the signature of the surgeon.
(ten) consultation records (including consultation opinions) refers to the records written by the applicant and the consultant respectively when the patient needs the assistance of other departments or other medical institutions during hospitalization. Consultation records should be written on a separate page. The contents include application for consultation records and consultation opinions records. The record of application for consultation shall briefly explain the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and shall be signed by the consultant. Regular consultation opinions should be recorded by the consultant within 48 hours after the consultation application is issued. In case of emergency consultation, the consultant should be present within 10 minutes after the consultation application is issued, and the consultation record should be completed immediately after the consultation. The consultation record includes the consultation opinions, the name of the department or medical institution where the consultant works, the consultation time, the signature of the consultant, etc. The applicant for consultation should record the implementation of the consultation in the course record.
(eleven) preoperative summary refers to the attending physician's summary of the patient's condition before operation. The contents include the brief illness, preoperative diagnosis, surgical indications, the name and method of the operation to be performed, the anesthesia method to be performed, matters needing attention, and the patient's relevant information recorded before operation.
(12) Preoperative discussion record refers to the discussion on the proposed operation mode, possible problems during operation and countermeasures under the auspices of the superior doctor before operation due to the patient's serious illness or difficulty in operation. The contents of the discussion include preoperative preparation, surgical indications, surgical plan, possible accidents and preventive measures, names and professional and technical positions of participants, specific discussion opinions and summary opinions of the host, discussion date, signature of the recorder, etc.
(13) Preoperative interview records refer to the records of risk assessment of anesthesia to be performed by anesthesiologists before anesthesia. Visit before anesthesia can set up a separate page or record the course of disease. The contents include name, sex, age, subjects, medical record number, general situation of patients, brief medical history, auxiliary examination results related to anesthesia, planned operation mode, planned anesthesia mode, anesthesia indications and anesthesia precautions, preoperative anesthesia doctor's orders, and the date signed by anesthesiologists.
(14) Anesthesia record refers to the record of anesthesia process and treatment measures written by anesthesiologists during anesthesia implementation. Anesthesia records should be written on a separate page, including the general situation of patients, special circumstances before anesthesia, medication before anesthesia, preoperative diagnosis, intraoperative diagnosis, operation mode and date, anesthesia mode, anesthesia induction and the start and end time of various operations, the name, mode and dosage of medication during anesthesia, special or unexpected circumstances and treatment during anesthesia, operation start and end time, and the signature of anesthesiologist.
(fifteen) the operation record refers to the special record written by the operator to reflect the general situation of the operation, the operation process, the findings and handling during the operation, and shall be completed within 24 hours after the operation. Under special circumstances, when written by the first assistant, it should be signed by the operator. The operation record should be written on a separate page, including general items (patient's name, gender, department, ward, bed number, inpatient medical record number or medical record number), operation date, preoperative diagnosis, intraoperative diagnosis, operation name, operator's and assistant's name, anesthesia method, operation process, intraoperative situation and treatment, etc.
(16) Operation safety verification records refer to the records made by surgeons, anesthesiologists and visiting nurses before anesthesia, before surgery and before the patient leaves the room, * * * to check the patient's identity, operation site, operation mode, anesthesia and operation risks, and inventory of items used in the operation. , and should also check the blood type and blood consumption of blood transfusion patients. There should be a tripartite inspection, confirmation and signature by the surgeon, anesthesiologist and visiting nurse.
(seventeen) the operation inventory record refers to the records of blood, instruments and dressings used by the visiting nurses during the operation, which should be completed immediately after the operation. The operation inventory record should be written on a separate page, including the patient's name, hospital medical record number (or medical record number), operation date, operation name, inventory check of the number of various instruments and dressings used in the operation, signature of visiting nurses and surgical instrument nurses, etc.
(eighteen) the first postoperative course record refers to the course record completed by the doctors who participated in the operation immediately after the operation. The contents include operation time, intraoperative diagnosis, anesthesia mode, operation mode, brief operation flow, postoperative treatment measures and matters needing special attention after operation.
(19) Post-anesthesia interview record refers to the record of the anesthesiologist visiting the patient's anesthesia recovery after anesthesia. Post-anesthesia visits can be set up on a separate page or recorded in the course of the disease. The contents include name, sex, age, subject, medical record number, general situation of patients, recovery from anesthesia, waking time, postoperative doctor's advice, whether to remove tracheal intubation, etc. If there are special circumstances, detailed records should be made, and the date should be signed by the anesthesiologist.
(twenty) the discharge record refers to the summary of the diagnosis and treatment of the patient during the hospitalization period by the attending physician, which should be completed within 24 hours after the patient is discharged. The contents mainly include admission date, discharge date, admission situation, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge situation, discharge orders, doctor's signature, etc.
(twenty-one) the death record refers to the record of the diagnosis, treatment and rescue of the deceased patient by the attending physician during his hospitalization, which shall be completed within 24 hours after the death of the patient. The contents include admission date, death time, admission situation, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of illness and rescue process), cause of death, death diagnosis and so on. Record the time of death to the minute.
(twenty-two) the discussion record of death cases refers to the discussion and analysis record of death cases presided over by the director of the department or a doctor with professional and technical qualifications above the deputy chief physician within one week of the patient's death. The contents include the date of discussion, the names of the moderator and participants, professional and technical positions, specific discussion opinions and moderator's summary opinions, and the signature of the recorder.
(twenty-three) the nursing record of patients with severe (critical) illness refers to the objective record of the nursing process of patients with severe (critical) illness during hospitalization according to the doctor's advice and illness. Nursing records of critically ill patients should be written according to the nursing characteristics of corresponding specialties. The contents include the patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other observations, nursing measures and effects, and nurse's signature. The recording time should be accurate to the minute.
Twenty-third surgical consent refers to the medical document that the attending physician informed the patient of the planned operation before the operation, and the patient signed whether or not to agree to the operation. The contents include preoperative diagnosis, operation name, possible complications during or after operation, operation risk, patient signature, signature of attending doctor and operator, etc.
Twenty-fourth anesthesia consent refers to the medical document that the anesthesiologist informs the patient of the anesthesia to be implemented before anesthesia, and the patient signs whether to agree to anesthesia. The contents include the patient's name, gender, age, medical record number, department, preoperative diagnosis, planned operation mode, planned anesthesia mode, patient's basic diseases and special circumstances that may affect anesthesia, planned invasive surgery and monitoring during anesthesia, anesthesia risk, possible complications and accidents, patient's signature and signature, and anesthesiologist's signature and date.
Twenty-fifth informed consent of blood transfusion treatment refers to the medical document that the attending physician informs the patient about the blood transfusion before blood transfusion, and the patient signs whether to agree to blood transfusion. The contents of the informed consent form for blood transfusion treatment include the patient's name, gender, age, subject, medical record number, diagnosis, blood transfusion indications, components to be transfused, relevant examination results before blood transfusion, blood transfusion risks and possible adverse consequences, patient's signature and signature, doctor's signature and date.
Twenty-sixth special examination and special treatment consent refers to the medical document that the attending doctor informs the patient of the special examination and special treatment before the implementation of the special examination and special treatment, and the patient signs whether to agree to the examination and treatment. The contents include special examination, the name and purpose of special treatment items, possible complications and risks, patient's signature, doctor's signature, etc.
Twenty-seventh critical (severe) notice refers to the medical documents that are informed by the attending physician or the doctor on duty to the patient's family and signed by the patient when the patient's condition is critical or serious. The contents include patient's name, gender, age, subjects, current diagnosis and critical condition, patient's signature, doctor's signature and date. In duplicate, one for the patient and one for the medical record.
Twenty-eighth doctor's advice refers to the doctor's advice issued in medical activities. Medical orders are divided into long-term medical orders and temporary medical orders.
The contents of the long-term medical order list include the patient's name, department, inpatient medical record number (or medical record number), page number, start date and time, long-term medical order content, stop date and time, doctor's signature, execution time and execution nurse's signature. The contents of temporary medical orders include the time of medical orders, the contents of temporary medical orders, the doctor's signature, the execution time and the execution nurse's signature.
The contents and starting and ending time of medical orders shall be written by doctors. The contents of doctor's orders should be accurate and clear, and each doctor's order contains only one content, and the release time should be indicated, specifically to minutes. The doctor's advice cannot be changed. When cancellation is required, the word "cancellation" should be marked with red ink and signed.
Under normal circumstances, doctors may not give oral orders. When oral medical advice is needed to rescue critically ill patients, nurses should repeat it. After the rescue, the doctor should fill the doctor's advice truthfully immediately.
Twenty-ninth auxiliary examination report refers to the records of various examinations and examination results made by patients during their hospitalization. The contents include the patient's name, gender, age, inpatient medical record number (or medical record number), examination items, examination results, report date, signature or seal of the reporter, etc.
Thirtieth temperature list in the form of tables, mainly by nurses to fill in. The contents include the patient's name, department, bed number, admission date, hospitalization medical record number (or medical record number), date, postoperative days, temperature, pulse, respiration, blood pressure, stool frequency, fluid volume, weight and hospitalization weeks.
Chapter IV Contents and Requirements of Printing Medical Records
Thirty-first printed medical records refer to medical records (such as Word documents, WPS documents, etc.). ) edit and print with word processing software. Print medical records should be entered and printed in time in accordance with the regulations, and signed by the corresponding medical personnel.
Thirty-second medical institutions should use unified paper, font, font size and typesetting format when printing medical records. The printed handwriting should be clear and easy to distinguish, and meet the requirements of medical record preservation and copying.
Thirty-third printed medical records shall be modified in accordance with the requirements of authority, and the printed and signed medical records shall not be modified. Article 34 The first page of inpatient medical records shall be written in accordance with the Notice of the Ministry of Health on Revising and Publishing the First Page of Hospitalized Medical Records (Wei [2001] No.286).
Thirty-fifth special inspection and special treatment shall be carried out in accordance with the relevant provisions of the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions (Order No.35 of the Ministry of Health 1994).
Article 36 The basic norms for writing medical records of traditional Chinese medicine shall be formulated separately by state administration of traditional chinese medicine.
Article 37 The basic norms of electronic medical records shall be formulated separately by the Ministry of Health.
Article 38 This Code shall come into force on March 1 day, 2065438. The Basic Specification for Medical Record Writing (Trial) promulgated by our Ministry in 2002 (No.2002190) shall be abolished at the same time.