Article 17 The contents of hospitalization medical records include the first page of hospitalization medical records, hospitalization records, temperature sheets, doctor's orders, laboratory tests (inspection reports), medical imaging examination data, special examination (treatment) consent, operation consent, anesthesia records, operation and operation nursing records, pathological data, nursing records, discharge records (or death records) and course records (including rescue)

article 18 the hospitalization diary refers to the records obtained by the attending doctor through consultation, physical examination and auxiliary examination after the patient is admitted to the hospital, and summarized, analyzed and written these materials. The writing forms of hospitalization records are divided into admission records, re-admission records, admission and discharge records within 24 hours, and admission and death records within 24 hours.

Admission records and re-admission records should be completed within 24 hours after the patient is admitted; The record of admission and discharge within 24 hours shall be completed within 24 hours after the patient is discharged, and the record of admission and death within 24 hours shall be completed within 24 hours after the patient dies.

Article 19 Requirements and contents of admission records:

(1) The general information of the patient includes name, sex, age, nationality, marital status, birthplace, occupation, date of admission, date of recording, onset solar terms and medical history.

(2) Chief complaint refers to the main symptoms (or signs) and duration that urge patients to see a doctor.

(3) 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 and combined with the requirements of TCM consultation to record the current situation. The contents include the incidence, the characteristics of main symptoms and their development and changes, accompanying symptoms, the course and 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.

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, drug allergy history, etc.

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

(6) Physical examination should be written in a systematic and orderly manner. The contents include body temperature, pulse, respiration, blood pressure, general conditions (including the look, shape, voice, breath, tongue picture, pulse, etc.), skin, mucosa, superficial lymph nodes of the whole body, head and its organs, neck, chest (chest, lungs, heart, blood vessels), abdomen (liver, spleen, etc.), rectum and anus, and external.

(7) the special situation of the specialty should be recorded according to the needs of the specialty.

(8) Auxiliary examination refers to the main examination related to this disease and its results made before admission. The date of inspection shall be stated, and if the inspection is conducted in other medical institutions, the name of the institution shall be stated.

(9) the initial diagnosis refers to the diagnosis made by the attending physician based on the comprehensive analysis of the patient's admission. If the initial diagnosis is multiple, the priority should be clear.

(1) the signature of the doctor who wrote the admission record.

Article 2 Re-admission records refer to records written by patients who have been admitted to the same medical institution for the same disease for the second time or many times. The requirements and contents are basically the same as the admission record, and its characteristics are as follows: the chief complaint records the main symptoms (or signs) and duration of the patient's admission; In the present medical history, it is required to summarize the previous hospitalization experiences before this hospitalization, and then write the present medical history of this hospitalization.

Article 21 If a patient is discharged within 24 hours after admission, a record of admission and discharge within 24 hours can be written. 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.

Article 22 If a patient dies less than 24 hours after being admitted to hospital, a record of death after being admitted to hospital within 24 hours can be written. 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.

Article 23 The course record refers to the continuous record of the patient's condition and the process of diagnosis and treatment after the hospitalization record. The contents include the patient's condition and syndrome changes, 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, and important matters to be informed to patients and their close relatives.

Article 24 Requirements and contents of course record:

(1) The first course record refers to the first course record written by the attending doctor 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 course record include case characteristics, diagnosis basis, differential diagnosis and treatment plan. The basis of diagnosis includes the basis of differentiation of diseases in traditional Chinese medicine and the basis of diagnosis in western medicine, and the differential diagnosis includes the differential diagnosis in traditional Chinese medicine and western medicine.

(2) Daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by doctors, but also by interns or probation medical staff. When writing the daily course record, first mark the record date, and record the specific content on a new line. For critically ill patients, the course of disease should be recorded at any time according to the change of the condition, at least once a day, and the recording time should be specific to minutes. For seriously ill patients, record the course of disease at least once every 2 days. For patients with stable condition, record the course of disease at least once every 3 days. For patients with chronic diseases whose condition is stable, the course of disease should be recorded at least once every 5 days.

(3) The records of superior doctors' rounds refer to the records of the patients' condition, symptoms, diagnosis, differential diagnosis, analysis of the curative effect of current treatment measures and suggestions for further diagnosis and treatment.

the attending physician's first rounds should be completed within 48 hours of the patient's admission. The contents include the name, professional and technical position, supplementary medical history and signs, diagnosis basis and differential diagnosis analysis and 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, professional and technical position, analysis of the condition and diagnosis and treatment opinions of the attending physician. The records of ward rounds made by the director of the department or doctors with professional and technical post qualifications above deputy chief physician, including the names of ward rounds doctors, professional and technical posts, analysis of illness and opinions on diagnosis and treatment, etc.

(4) The discussion record of difficult cases refers to the record that is presided over by the director of the department or a doctor with professional and technical post qualifications above the deputy chief physician and convened by relevant medical personnel to discuss cases with difficult diagnosis or uncertain curative effect. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.

(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 shift record shall be written by the shift doctor before the shift; The succession record shall be completed by the succession doctor within 24 hours after the succession. The contents of the handover record include the date of admission, handover or succession, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in handover or succession diagnosis and treatment plan, and doctor's signature, etc.

(6) the record of changing one's major refers to the records written by the doctors in the transfer department and the doctors in the transfer department respectively after the patients need to change one's major during their hospitalization. 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 in case of emergency); Transfer-in records shall be completed by doctors in transfer-in departments within 24 hours after patients are transferred in. The contents of the transfer record include admission date, transfer-out or transfer-in date, patient's name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in transferring subjects or transfer-in treatment plan, and doctor's signature.

(7) stage summary refers to the monthly summary of the patient's condition and diagnosis and treatment by the attending doctor after a long hospitalization. The contents of the stage summary include the date of admission, 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.

the shift handover record and the shift change record can replace the stage summary.

(8) the rescue record refers to the record made when the patient is in critical condition and takes rescue measures. The contents include the change of illness, the time and measures of rescue, the names of medical personnel who participated in the rescue and their professional and technical positions. Record the rescue time should be specific to minutes.

(9) consultation records (including consultation opinions) refer 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. The contents include application for consultation records and consultation opinions records. The record of application for consultation shall briefly state the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and the signature of the consultant. The consultation opinion record shall contain the consultation opinion, the name of the department or medical institution where the consultant is located, the consultation time and the signature of the consultant, etc.

(1) Preoperative summary refers to the summary of the patient's condition made by the attending physician before the operation. The contents include brief illness, preoperative diagnosis, operation indications, name and mode of operation to be performed, mode of anesthesia to be performed, matters needing attention, etc.

(11) Pre-operation discussion record refers to the record of discussing the planned operation mode, possible problems and countermeasures during the operation under the auspices of the superior doctor before the operation because the patient is seriously ill or the operation is difficult. The contents include preoperative preparation, surgical indications, surgical plan, possible accidents and preventive measures, names of participants, professional and technical positions, discussion date, signature of recorder, etc.

(12) 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, medication before anesthesia, preoperative diagnosis, intraoperative diagnosis, anesthesia mode, medication and treatment during anesthesia, starting and ending time of operation, signature of anesthesiologist, etc.

(13) Operation record refers to the special record written by the operator, which reflects the general situation of the operation, the process of the operation, the findings and treatment during the operation, and should be completed within 24 hours after the operation. Under special circumstances, when written by the first assistant, it should be signed by the operator. Surgical records 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, names of operators and assistants, anesthesia methods, operation process, situations and treatment during operation, etc.

(14) Surgical nursing records refer to the records made by visiting nurses on the nursing situation of surgical patients during operation and the instruments and dressings used, which should be completed immediately after the operation. Surgical nursing records should be written on a separate page, including the patient's name, hospital medical record number (or medical record number), operation date, operation name, intraoperative nursing situation, counting and checking the number of various instruments and dressings used, and signatures of visiting nurses and surgical instrument nurses.

(15) The first course record after operation refers to the course record completed by the doctors participating in the operation immediately after the operation. The contents include operation time, intraoperative diagnosis, anesthesia mode, operation mode, brief operation process, postoperative treatment measures and matters that should be paid special attention to after operation.

Article 25 The consent for operation refers to the medical document that the attending doctor informs the patient about the operation to be performed before the operation, and the patient signs the consent for the operation. The contents include preoperative diagnosis, operation name, possible complications during or after operation, operation risk, patient's signature, doctor's signature, etc.

Article 26 The consent for special examination and special treatment refers to the medical document that the attending doctor informs the patient about the special examination and special treatment before the implementation of the special examination and special treatment, and the patient signs the consent for the examination and treatment. The contents include special examination, name and purpose of special treatment items, possible complications and risks, patient's signature, physician's signature, etc.

Article 27 The discharge record refers to the summary made by the attending physician on the diagnosis and treatment of the patient during this hospitalization, which shall 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 doctor's advice, doctor's signature, etc.

Article 28 Death record refers to the record of the diagnosis, treatment and rescue of a deceased patient during hospitalization by the attending physician, 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. Recording the time of death should be specific to minutes.

Article 29 The discussion record of death cases refers to the record in which the death cases are discussed and analyzed within one week after the death of the patient, presided over by the director of the department or a doctor with professional and technical post qualifications above the deputy chief physician. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.

Article 3 Medical orders refer to medical instructions issued by doctors in medical activities.

the contents of the doctor's advice and the start and stop time should be written by the doctor.

the contents of medical orders should be accurate and clear, and each medical order should contain only one content, and indicate the release time, which should be specific to minutes.

the doctor's advice should not be altered. When cancellation is required, the word "cancellation" shall be marked in red ink and signed.

under normal circumstances, doctors are not allowed to give oral orders. When it is necessary to give oral medical advice for rescuing critically ill patients, the nurse should repeat it. After the rescue, the doctor should immediately make up the doctor's orders according to the facts.

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 signature of doctors, the execution time, and the signature of executing nurses.

article 31 the auxiliary examination report refers to the records of various tests 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.

Article 32 The temperature list is in tabular format, which is mainly filled out by nurses. The contents include the patient's name, department, bed number, admission date, hospitalization medical record number (or medical record number), date, days after operation, temperature, pulse, respiration, blood pressure, stool frequency, fluid volume, weight, and hospitalization weeks.

Article 33 Nursing records are divided into general patient nursing records and critically ill patient nursing records.

The nursing record of general patients refers to the objective record of the nursing process of general patients during hospitalization by nurses according to the doctor's advice and illness. The contents include patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, observation of illness, nursing measures and effects, and nurse's signature.