First of all, the name of the hospital ..., the patient's name, department, bed number, hospitalization number, and then the following contents:
1, date of admission and discharge, length of stay.
2. Disease summary and diagnosis at admission. Changes of illness and diagnosis and treatment during hospitalization.
3, the situation at the time of discharge, including symptoms and signs, the degree of recovery of the disease, sequelae, etc.
4. Discharge diagnosis.
5. Discharge order: including matters needing attention and suggestions, bringing back the name, quantity, dosage and usage of drugs.
6. The discharge record should be completed within 24 hours after discharge; The hospitalization process written in outpatient medical records can also refer to the above requirements, but it needs to be more concise and record various main figures, such as hospitalization number, CT, MRI and X-ray number.
Extended data
Outpatient medical records
1, the cover content of outpatient medical records should be carefully filled in item by item. Fill in the patient's name, gender, age, work unit or address, outpatient number and public (self) fee from the registration room. X-ray number, electrocardiogram and other special inspection numbers, drug allergy, hospitalization number, etc. It should be filled out by a doctor.
2. The medical records of newly diagnosed patients should include "five signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and doctor's signature). These include:
(1) Medical history should include present medical history, past medical history, personal history related to diseases, marriage, menstruation, birth history, family history, etc. ;
② Physical examination should record the main positive bodies and negative signs with differential diagnosis significance.
(3) List the names of diseases that are initially diagnosed or most likely, and try to avoid using words such as "to be investigated" and "to be diagnosed".
(4) The treatment opinions should list the drugs used and special treatment methods, further examination items, matters needing attention in life, rest methods and time limit; If necessary, record the appointment date and follow-up requirements.
3. Follow-up patients should focus on the diagnosis and treatment results and the evolution of the disease after the previous follow-up; Physical examination can focus on the last positive discovery and the newly discovered signs; Supplementary necessary auxiliary inspection and special inspection. For patients who cannot be diagnosed for three times, the attending doctor should ask the superior doctor for consultation. For diseases different from last time, all outpatient medical records should be written according to newly diagnosed patients.
4, each visit should fill in the date of visit, emergency patients should fill in the specific time.
5. It is required that the purpose, requirements and preliminary opinions of the undergraduate course should be clearly filled in the medical records and signed by senior doctors in our hospital.
6. Invited consultants (senior doctors in our hospital) should fill in the examination results and diagnosis opinions on the consultation medical records for instructions.
7. If the outpatient department needs hospitalization examination and treatment, the doctor shall fill in the hospitalization certificate.
8. The outpatient physician is responsible for filling in the medical record summary of the referred patient.
9, the legal epidemic situation report of infectious diseases should be indicated.
Baidu Encyclopedia-Medical Records
Baidu encyclopedia-discharge record