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 and complete.
Article 4 The inpatient medical records shall be written in blue-black ink and carbon ink, and the outpatient (emergency) medical records and photocopied materials may be written in blue or black oil-water ballpoint pen.
Article 5 Medical records shall be written in Chinese and medical terms. Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages. The use of TCM terms should be implemented in accordance with relevant standards and norms.
Article 6 The writing of medical records shall be neat, clear, accurate, fluent and punctuated. When typos appear in the writing process, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting.
Seventh medical records should be written in accordance with the provisions, and signed by the corresponding medical personnel.
Medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution.
Medical personnel receiving continuing education should write medical records after being approved by medical institutions receiving continuing education according to their actual qualifications for professional work.
Eighth superior medical personnel have the responsibility to review and modify the medical records written by lower medical personnel. When modifying, the date of modification shall be indicated, and the signature of the modifier shall be clear and readable.
Ninth because of the rescue of critically ill patients can not write medical records in time, the relevant medical personnel shall truthfully fill in the record within 6 hours after the rescue, and make records.
Article 10 The diagnosis involved in the writing of medical records includes the diagnosis of traditional Chinese medicine and the diagnosis of western medicine, among which the diagnosis of traditional Chinese medicine includes the diagnosis of disease and syndrome. Chinese medicine treatment should follow the principle of syndrome differentiation and treatment.
Eleventh medical activities (such as special examination, special treatment, surgery, experimental clinical treatment, etc.). If the patient's written consent is required in accordance with relevant regulations, it shall be signed by the patient himself. When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; If the patient is unable to sign due to illness, it shall be signed by his close relatives; if there are no close relatives, it shall be signed by his related person; In order to rescue patients, if the legal representative or close relatives or related parties cannot sign in time, the person in charge of the medical institution or the authorized person in charge may sign.
If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's close relatives shall be informed of the relevant situation, and the close relatives of the patient shall sign the consent form and record it 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.