If the writing of outpatient medical records is wrongly revised, it shall be marked with typos with double lines, and the original records shall be kept clear and easy to read, indicating the time of revision and signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting. Don't tear up the outpatient medical records and rewrite them.

For hospitals that use outpatient electronic medical records, once the patient's visit is over, it is regarded as a medical record file, and it is not recommended to change it in any form.

In-patient surgical records

For the personal basic information errors such as the patient's name, gender, age, address and ID number in the running medical records, the bed management doctor or the superior doctor can correct them in time according to the Basic Specification for Medical Records Writing.

Problems involving misdiagnosis or missed diagnosis should be recorded in the course record, and corrected diagnosis and supplementary diagnosis should be recorded in the admission record, rather than directly modifying the admission diagnosis.

For medical records involving physical examination, treatment measures, surgical records, etc., it is suggested that they be reviewed, revised and signed by superior doctors. Use the job number of the superior doctor to modify the electronic medical record, so as to avoid the bed management doctor from directly modifying it himself.

If there are mistakes in conversation record and the informed consent form that need to be revised, and if they are found before surgery or treatment, conversation record and the informed consent form need to be rewritten immediately and re-signed by patients or their families. If it is found after surgery or treatment, it is not recommended to modify it. The contents of conversation record and informed consent signed by patients or their families shall not be added, deleted or modified.