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The medical records of newly diagnosed patients should contain five signatures: (chief complaint, medical history, physical examination, preliminary diagnosis, treatment advice and doctor's signature), in which the medical history should include current medical history, past history, personal history related to the disease, marriage, menstruation, birth history, family history, etc.

Matters needing attention related to medical records:

Medical records should not only be carefully recorded, but also important contents, such as whether the patient's family members will not undergo surgery, whether they will consider the family members of surgery again, and whether they will consider targeted treatment for economic reasons.

Clinical treatment should fully respect the personal wishes of family members and patients, especially tumors.

What family members describe after seeing a doctor in several hospitals will be incomplete for various reasons, so we must understand it clearly and don't easily blame doctors in other hospitals for their diagnosis and treatment.

There may be mistakes in the writing of medical records, but don't alter or change them afterwards, keep the original records and make supplementary explanations and corrections in the next medical record.

Keeping the original medical records is good for both hospitals and patients.