Legal basis: the basic standard of medical record writing
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 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.