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Is the writing manual of internship medical records a big medical record?
Yes Taking Shanghai Affiliated Hospital as an example, interns are required to write large medical records as part of the admission records of hospitalization records. Medical record is a comprehensive record and summary of the diagnosis and treatment process of patients and the clinical work of doctors at all levels, and it is an indispensable and important legal material for medical treatment, teaching, scientific research and justice. Medical record writing is a basic clinical skill that students majoring in clinical medicine and pediatrics must master.