order

Medical record refers to the relevant information obtained by medical staff through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, so the content of medical record writing can reflect the medical quality, academic level and management level of the hospital, so it has become the focus of medical units at all levels. At present, all provinces and cities in China have their own versions of medical record writing norms. Although the contents are basically the same, the requirements for the connotation of medical records in some medical, teaching and scientific research fields still cannot meet the unified standard requirements. In order to better serve patients, standardize medical record writing, improve the quality of medical record writing and make medical information serve the current medical and health reform, it will be beneficial to improve medical quality, teaching quality and scientific research level to formulate a unified national medical record writing standard; It also improves doctors' legal awareness and academic level of medical record writing, and makes medical record information resources serve patients and society more widely.

Entrusted by China Hospital Management Association and supported by the National Medical Record Management Committee, the National Medical Record Quality Monitoring Committee organized and formulated a unified national medical record writing standard and scoring sub-standard (trial draft). This trial draft has gone through the following four stages;

The first stage: based on the accreditation standards of tertiary hospitals in Beijing, the first draft (discussion draft) of medical record writing norms was drafted on the basis of collecting some provincial and municipal medical record writing norms. With the support of China Hospital Management Association, in the fourth quarter of 2000, more than 40 experts from more than 20 hospitals in Beijing were invited to organize this meeting.

The second stage: With the support of China Hospital Management Association and Medical Records Professional Committee, the National Medical Records Quality Monitoring Committee was held in Beijing in May, 20001. More than 20 medical record quality monitoring experts from all provinces and cities in China discussed the discussion draft, and then according to the opinions and suggestions discussed at the meeting and the feedback from all provinces and cities after the meeting, the second draft of the Medical Record Writing Standard (discussion draft) was compiled.

In the third stage, the Medical Record Writing Standard (discussion draft) passed the inaugural meeting of the National Medical Record Quality Monitoring Committee +0 1 65438 held in Shanghai on October 9, 2006, and the whole Committee organized a big discussion again to collect opinions from many parties. After the meeting, I brought it back to the local area for feedback from various provinces and cities and revised it again. It is mainly to delete most of the requirements that are difficult to meet, and to increase one-vote veto (that is, the lack of a clause for unqualified B or C medical records) to form the Medical Record Writing Specification (Trial Draft).

The fourth stage; After the Regulations on Handling Medical Accidents was promulgated by Xinhua News Agency authorized by the State Council on April 14, 2002, the Basic Specification for Medical Record Writing (Trial), one of its supporting documents, was publicized nationwide on August 6, 2002, and also absorbed from September 5438, 2006 to August 2002. Under the leadership of the Ministry of Health and the Beijing Municipal Health Bureau, During the inspection of the evaluation pilot, I feel very convenient and good.

It has also been well received. In Beijing, we were discussed by members of the National Medical Record Quality Monitoring Committee twice, and we also listened to the opinions of some experts in Beijing on medical record writing. In September, 2002, we revised the Basic Norms of Medical Record Writing (Trial) (discussion draft), and on February 4th, 2002, it was discussed and passed by the Beijing Municipal Committee, forming the current Norms and Grading Standards of Medical Record Writing (Trial). It was revised and finalized on June 20th, 2003.

This book "Medical Record Writing Standard" (Trial Draft) can be used as the standard requirement of medical record writing in hospitals with medical, teaching and scientific research tasks in China, and can be used to train young doctors for hospital evaluation and evaluation. Each province and city may, according to its own specific conditions and referring to the above contents, formulate provinces and cities that are more suitable for the specific requirements of the region.

Thanks to all the hospitals and experts involved in the formulation and discussion for their support.

National Medical Records Quality Monitoring Committee

Draft 2002/ 1/8

2002/ 12/4 finalized

2003/ 1/20 revised edition

The first chapter is the significance of medical record writing.

Medical record is a systematic record about the occurrence, development, diagnosis and treatment of patients' diseases; It is a medical file that clinicians summarize, analyze, sort out and write according to the information obtained from consultation, physical examination, auxiliary examination and detailed observation of the condition.

The medical record not only truly reflects the patient's condition, but also directly reflects the medical quality, academic level and management level of the hospital. Medical records not only provide extremely valuable basic data for medical treatment, scientific research and teaching, but also provide indispensable medical information for hospital management. When it comes to medical disputes, medical records are an important basis to help determine legal responsibilities; In the reform of the basic medical insurance system, medical records are the proof of medical payment.

Writing complete and standardized medical records is the basic method to cultivate the clinical thinking ability of clinicians and an important way to improve their professional level. The quality of medical record writing is one of the objective test standards to assess the practical working ability of clinicians. Every clinician should carefully write medical records with a highly responsible professionalism and a realistic scientific attitude, as Professor Zhang said. "The stage of writing big medical records is very important. It is necessary to form a lifelong habit through it, that is, it can be used as a conditioned reflex in busy outpatient clinics, and no key points are missed in the process of diagnosis and treatment of patients. This kind of training is short-lived and fleeting. Once you quit school, you can't make up for it. Don't take it lightly. "

Let us remember the teaching efforts of Professor Zhang, an older generation of clinicians and medical educators. May our medical staff be interested in this disease.

People's caring, caring and responsible spirit, rigorous, meticulous, diligent and dedicated spirit are embodied in the whole medical record through medical record writing.

Between the lines, medical records have made greater contributions to medical treatment, teaching, scientific research, prevention, hospital management and legal system.

Chapter II Composition of Medical Records and Matters Needing Attention in Writing

First, the composition of medical records

(1) Medical records include outpatient (emergency) medical records and inpatient medical records.

A complete medical record should include all written records related to the diagnosis and treatment of patients. Generally divided into outpatient (emergency) medical records (including emergency observation medical records) and hospitalization medical records.

1, outpatient (emergency) medical records, is the patient's outpatient (emergency) medical records, written by the attending physician.

2. Hospitalization medical records: various medical records written by ward doctors and other relevant medical personnel after the patient has gone through the hospitalization procedures.

(2), outpatient medical records have the following contents:

1, outpatient medical record home page;

2, door (emergency) medical records.

3. Outpatient alkalization, special examination sound and imaging report.

(3) The inpatient medical records are composed of the following contents (sorted by discharge medical records);

1. Home page of inpatient medical records: it is required to write down the primary diagnosis and secondary diagnosis.

2. Admission records and hospital medical records (i.e. large medical records written by interns).

3. Course record (first course record, daily course record, first round record, daily round record, consultation record, handover record, stage summary, transfer-out record, preoperative discussion, preoperative summary, anesthesia record, operation record, postoperative course record, rescue record, etc.). ).

4, discharge records or death records and death discussion.

5. Laboratory and other auxiliary inspection reports.

6, body temperature list.

7, doctor's advice.

8, nursing records.

9, surgery report or informed consent of surgery and trauma examination and treatment, blood transfusion, self-funded drugs and other informed consent.

Key requirements for writing hospital medical records

1, chief complaint writing

The chief complaint is a brief summary of the main symptoms, signs and their nature, location, degree and duration. The main symptoms and time limit should be focused, highly summarized and concise, and the diagnosis or examination should not be used instead of the chief complaint. If there is more than one chief complaint, it is listed in the order of occurrence, such as recurrent epigastric pain for 65,438+00 years, intermittent hematochezia for 65,438+0 years, and hematemesis for 4 hours.

2. Writing of contemporary medical history

The present medical history is a detailed description of the whole process of disease from onset to treatment, including the following aspects:

1) seizure: the time and place of the first symptom seizure, the urgency of the seizure, the precursor symptoms, the seizure symptoms and their severity, and the possible causes or incentives.

2) Main symptoms, characteristics and evolution; According to the sequence of main symptoms and the process of evolution and development, we should describe the characteristics of main symptoms in different levels, such as nature, location, degree and duration. Efforts should also be made to find out the causes of symptoms and relieve them.

3) Accompanying symptoms: ask about the relationship between accompanying symptoms and main symptoms, and further judge the location and nature of the disease and the evolution of the disease.

4) Diagnosis and treatment since the onset and results: No matter the examination done in our hospital or other hospitals, the diagnosis and treatment results should be recorded in detail. If the written materials held by patients or the materials provided orally by patients are made in other hospitals, they should be marked with a red sign ("") to distinguish them from those in our hospital.

5) Changes in general conditions since the onset should be recorded, such as mood, mental state, living habits, posture, salivation, appetite, defecation, weight, etc.

6) If the patient's death or other accidents are related to the disease, we must strive to record the illness and physical examination objectively and truly, and we must not make subjective inferences or guesses, and the diagnosis should be based.

7) Positive or negative data related to differential diagnosis should not be omitted.

8) It is necessary to describe the past onset, diagnosis and treatment related to this disease in detail.

9) If you need to treat other diseases unrelated to this disease, it should be briefly described in another paragraph of the current medical history.

3. Writing requirements of past history

Past history is a description of the diseases that have been suffered or diagnosed before the onset of this disease, which is generally an independent disease that has nothing to do with or related to this disease. Its contents include: health status, history of infectious diseases, history of vaccination, history of surgical trauma, history of allergy (food and drugs), history of application of important drugs, systematic review (diagnosis and treatment of symptoms or diseases related to respiratory system, circulatory system, digestive system, genitourinary system, blood system, endocrine and metabolic system, nervous system, exercise skeletal system, immune system, etc. ). Write in the required fixed order.

4, the basic content of medical requirements

Make a comprehensive and systematic order from top to bottom to avoid omissions. (See admission records and hospital medical records for details. )

5. Requirements for writing medical records summary

It is a part of the inpatient medical record (large medical record), which is mainly the training content for interns. It is required to briefly describe the chief complaint, present and past history, physical examination and laboratory or special examination results, admission diagnosis or discharge diagnosis and treatment process, etc.

6. The writing requirements of the proposed consultation.

It is a part of the inpatient medical record (large medical record). According to the summary of medical history, write the characteristics of medical records, and systematically discuss diagnosis and differential diagnosis. Generally, the most definite diseases are discussed first, and the diagnosis basis is put forward. Through analysis and reasoning, the reasons are given, and then the possibility of diagnosis is affirmed and ruled out. If there are more than two diseases, first discuss the main disease, then discuss the secondary disease, and then discuss the complications and accompanying diseases. For cases that are difficult to diagnose or to be diagnosed, list the possible diagnoses, and then rule them out one by one according to the size of the possibility, leaving the diagnosis with greater possibility. In diagnosis and exclusion, it is necessary to put forward the key laboratory tests and special tests that should be done, and interns and residents can put forward their own specific diagnosis and treatment plans (this is the need of professional training).

Writing requirements of course records

(a), the first course of writing requirements

Generally, it should be written by the resident who wrote the hospitalization record. Residents are required to finish it in time (within 8 hours). The contents include:

1), medical record characteristics; 2), diagnosis basis; 3), differential diagnosis and treatment plan. It is required to grasp the main points, be analytical and insightful, and fully reflect the clinical thinking activities of residents. Don't write anything that doesn't belong to the diagnosis and treatment plan, and avoid writing the words "complete the medical record writing" and "ask the superior doctor" in the diagnosis and treatment plan.

(2) Requirements for writing daily course records

It can be written by residents and interns, and the interns must be reviewed and signed by the superior doctors after writing. When writing the course record, a separate line should be set up, and the record date should be marked, and the specific time should be recorded for critically ill patients. The content of the record requires concise text, prominent focus and in-depth discussion and analysis. The contents of the course record shall include:

1. The changes of illness should be recorded in time: the symptoms and signs of the patient, especially the newly emerging symptoms and signs, and the general situation of the patient, including mood, consciousness, diet, exercise, sleep, body temperature, defecation, etc. At the same time, the changes, complications and possible causes of the disease were analyzed and discussed. It is necessary not only to record the reasons, effects and adverse reactions of the treatment measures, but also to learn to read the literature and put forward personal opinions on the diagnosis and treatment of patients according to their illness. When changing the doctor's advice, it is necessary to explain the reasons for stopping the treatment plan and increasing the treatment measures, and the content should be specific.

2. Important laboratory tests and special tests need to judge the results, analyze their significance in diagnosis and treatment, make comparison before and after, and take measures, and make specific records.

3, should record all kinds of diagnosis and treatment projects in the process of diagnosis and treatment. Patients' informed consent should be signed before the operation (diagnosis and treatment) with trauma, and detailed records should be made after the operation, such as various intubation angiography, interventional therapy, large puncture biopsy, etc. , including preoperative work, conversation and signature with family members, operation process, intraoperative findings, whether patients feel adverse reactions during and after operation, changes in vital signs, whether specimens are collected during operation, whether they are sent for inspection and report the results should be recorded in detail. The name of the operator must be recorded.

(3), level 3 rounds record writing requirements

Course records should reflect the situation of "three rounds" in time and accurately. Residents should record in detail the analysis opinions of doctors at all levels on the condition, important doctor's orders and the reasons for changing the doctor's orders, such as the basis for medication and dressing change. , and record the name, professional title and specific speech content of the spokesperson, which cannot be written into the comprehensive opinions of multiple spokespersons.

1, requirements for resident rounds:

Residents should complete early rounds and late rounds at least once a day, and record important information in the course record. The course record of critically ill patients is required to be recorded at any time according to the change of illness; Serious illness, recorded once a day or every other day; Cases with stable condition can be recorded twice a week for no more than 5 days. For special chronic diseases, the condition is stable, and in order to observe the laboratory indicators, such as hepatitis, tuberculosis, silicosis and other course records can be extended to once a week.

2, the requirements of attending physician rounds record

According to the patient's condition, the specific requirements of the attending physician's rounds are as follows:

(1), the first round

1), critically ill patients should have superior doctors (including attending doctors) on the day of admission.

2), seriously ill after admission, the next day to have a superior doctor rounds record.

3), general patients after admission, the attending physician rounds for the first time shall not exceed 48 hours, after admission, the interval between the attending physician rounds for the second time and the first time shall not exceed 3 days.

4) Holidays and weekends are no exception to the above rounds. The chief resident or the second-line doctor on duty can make rounds, and only medical problems are required to be solved at this time.

5) The first round: it is required to verify whether the medical history written by junior doctors has been supplemented and whether there are new findings in physical signs. Tell the diagnosis basis and differential diagnosis, and put forward the next diagnosis and treatment plan and specific doctor's advice.

(2), routine rounds of records

1), for severe cases, follow the doctor's advice: it is required to have superior rounds every day (including attending doctors), at least once a day.

2) Patients with severe illness should be checked once a day or every other day according to the doctor's advice, and the longest interval should not exceed three days.

3) General patients: According to the illness, rounds are usually made twice a week, and the longest time is no more than 5 days. The longest rounds for patients with chronic diseases shall not exceed 7 days (the sanatorium shall be set up separately). When the condition changes rapidly, such as heart disease and pediatric diseases, it is required to make rounds at least 2 13 times a week.

(3), for patients with unclear diagnosis or treatment difficulties, please ask the department director to make rounds, and the professional team will help solve it.

(4), for difficult cases and cases of teaching value, to the department director to organize general rounds on a regular basis.

3, chief physician and deputy chief physician rounds record requirements

For cases with unclear diagnosis, poor treatment or serious and difficult conditions, doctors above the director or deputy director must be asked to help solve relevant problems in time, and residents should make detailed records. According to the condition, there should be a professional group to make rounds when necessary. The contents of ward rounds in tertiary hospitals should not only solve difficult medical problems, but also carry out teaching ward rounds, which can reflect the latest level of medical development at home and abroad.