The basic requirements for medical care documentation are: objective, truthful, accurate, timely and complete.

The basic requirements for medical care documentation are:

(1) Objective, truthful, accurate, timely and complete;

(2) Use blue and black ink Or written with carbon ink;

(3) Use Chinese and medical terminology. Common foreign language abbreviations and symptoms, signs, disease names without official Chinese translations can be used in foreign languages;

(4) The writing is neat, the handwriting is clear, the expression is accurate, the sentences are smooth, and the punctuation is correct. When a typo occurs during writing, double lines should be used to mark the typo, and methods such as scraping, gluing, and coating are not allowed to cover up or remove the original handwriting;

(5) Write in accordance with the prescribed content, and be Signature of the corresponding medical staff;

(6) Superior medical staff have the responsibility to review and modify medical records written by subordinate medical staff.

When making modifications, the date of modification should be indicated, the signature of the person making the modification should be noted, and the original record should be kept clear and defensible;

(7) If the medical record cannot be written in time due to rescuing critically ill patients, the relevant medical personnel shall Make additional records according to the facts within 6 hours after the rescue is completed, and indicate it;