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How to write outpatient medical records
Medical record writing

1. The contents of outpatient (emergency) medical records include the first page of outpatient (emergency) medical records (the cover of outpatient (emergency) manual), medical records, laboratory tests (inspection reports), medical imaging data, etc.

2. The first page of outpatient (emergency) medical records should include the patient's name, gender, date of birth, nationality, marital status, occupation, work unit, address, drug allergy history and other items.

3, outpatient manual cover content should include the patient's name, gender, age, work unit or address, drug allergy history and other items.

Extended data:

1, 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 medical activity records.

2, medical records should be objective, comprehensive, true, accurate, timely, complete and standardized.

3, medical records should be written in blue and black ink, carbon ink, medical records to be copied can use blue or black oil-water ballpoint pen. Computer printed medical records shall meet the requirements of medical record preservation.

4. Medical records should be written in Chinese, and commonly used abbreviations in foreign languages and names of symptoms, signs and diseases without official translation in Chinese can be written in foreign languages.

5. Medical records should be written in standardized medical terms, with neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation.

6. In the process of medical record writing, typos should be marked with double lines, and the original records should be clear and easy to read, indicating the revision time, 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.

Baidu Encyclopedia-Basic Specification for Medical Record Writing