Article 1 Medical records refer to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records.

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, comprehensive, true, accurate, timely, complete and standardized.

Article 4 Medical records shall be written in blue-black ink and carbon ink, and copied medical records may be written in blue or black oil-water ballpoint pen. Computer printed medical records shall meet the requirements of medical record preservation.

Article 5 Medical records shall be written in Chinese, and commonly used abbreviations in foreign languages and names of symptoms, signs and diseases without official Chinese translation may be written in foreign languages.

Article 6 Medical terms shall be standardized in the writing of medical records, with neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation.

Article 7 When typos appear in the process of writing medical records, they shall be marked with double lines, and the original records shall be kept clear and readable, with the time of revision indicated and signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting.

The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff.

Eighth medical records should be written in accordance with the provisions, and signed by the corresponding medical personnel.

The medical records written by medical practitioners and trainees shall be reviewed, revised and signed by medical personnel registered in this medical institution.

Medical institutions shall, according to their own actual situation, write medical records after confirming that medical personnel are competent for their professional work.

Article 9 The date and time of medical records shall be written in Arabic numerals, and a 24-hour system shall be implemented.

Tenth medical activities that require the written consent of patients shall be signed by the patients themselves. When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; When the patient is unable to sign due to illness, it shall be signed by the person authorized by him;

In order to rescue patients, if the legal representative or the authorized person cannot sign in time, the person in charge of the medical institution or the authorized person may sign.

If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, it shall inform the patient's close relatives, and the informed consent form shall be signed by the patient's close relatives and recorded 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.

Extended data

legal provision

Notice of the Ministry of Health on Printing and Distributing the Basic Norms for Medical Record Writing No.206543810? [ 1]?

Health bureaus of all provinces, autonomous regions and municipalities directly under the Central Government, and Health Bureau of Xinjiang Production and Construction Corps:

In order to standardize the medical record writing behavior of medical institutions in China, improve the quality of medical records, and ensure medical quality and medical safety, in 2002, according to the relevant provisions of the Regulations on Handling Medical Accidents, our department issued the Basic Specification for Medical Record Writing (for Trial Implementation) (hereinafter referred to as the Specification).

With the joint efforts of health administrative departments at all levels and medical institutions, the quality of medical records in medical institutions in China has been greatly improved since the implementation of the Code for more than seven years.

On the basis of summarizing the implementation of local norms, our department revised and improved the norms and formulated the Basic Norms for Medical Record Writing, combined with the new situation and new characteristics faced by the management of medical institutions and medical quality management. It is issued to you, please follow it. The situation and problems encountered in the implementation, timely reflect to the Department of medical administration.

20 10 year 1 month 22nd

References:

Baidu Encyclopedia-Basic Specification for Medical Record Writing