(2) Medical staff should use blue-black ink or carbon ink when writing hospital medical records, including the revision of medical records by superior doctors, unless the doctor's orders need to be cancelled and marked "Cancel" and signed. Electronic medical records should keep the traces and time of doctor's revision.
(3) Medical records should be written in Chinese and medical terms. Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages.
(4) It is forbidden to alter the writing of medical records. When there is a typo in the writing process, you should draw double horizontal lines on the typo and correct it in the blank. Scraping, pasting, pasting, wiping, drawing and other methods are not allowed to cover up or remove the original handwriting, making it unrecognizable.
(5) According to relevant regulations, medical records should be written in accordance with regulations and signed by corresponding medical personnel. Practitioners and trainee medical personnel, as well as senior medical personnel who have not yet obtained the legal right to practice, can only write "daily course records", which need to be reviewed, revised and signed by higher-level doctors.
(6) The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff. When revising, if there are typos or sentences, draw them with double horizontal lines; If it is added, write it in the blank space on the premise of keeping the original record clear and distinguishable; Finally, indicate the revision time, revision times and sign.
(7) the requirements of the doctor's rounds. The attending physician's first rounds should be completed within 48 hours after the patient is admitted to the hospital. For critically ill patients, the course record should be written at any time according to the change of illness.
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At least 1 time every day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days. Deputy chief physician and doctors with technical titles or above make rounds 1~2 times a week.
(8) Strictly implement the Basic Norms for Medical Record Writing and the provisions of the document Weifa (2010)1:"If the medical record cannot be written in time due to the rescue of critically ill patients, the relevant medical personnel shall make up the record according to the facts within 6 hours after the rescue and make records.
(9) Any medical activity that requires the written consent of the patient must be signed by the patient himself or his close relatives or legal representatives and indicate the relationship with the patient. If the signer can't read, he can use handprint instead of logo (right thumb, left thumb in case of missing right thumb, and mark it after covering).
(10) Implementing "protective medical measures" means that it is not appropriate to explain the situation to patients for certain special diseases or high-risk medical operations, and the patient's close relatives should be informed of the relevant situation, and the patient's close relatives should sign the consent form and record it in time. If the patient is unable to sign the consent form without close relatives or close relatives, the consent form shall be signed by the patient's legal representative or relevant person. Medical institutions may, according to needs, require their close relatives or legal representatives to obtain the power of attorney of patients in advance.
(1 1) According to the Regulations on Medical Records Management of Medical Institutions (version 20 13), the inpatient medical records should be sorted in the following order; Temperature list, doctor's advice list, admission record, course record, preoperative discussion record, operation consent, anesthesia consent, preoperative visit record, operation safety verification record, operation inventory record, anesthesia record, operation record, postoperative visit record, postoperative course record, nursing record of severe (critical) patients, discharge record, death record, informed consent of blood transfusion treatment, and special examination (special treatment).
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Critical (critical) notice, pathological data, auxiliary examination report and medical imaging examination data.
The medical records are bound and kept in the following order: home page of hospital medical records, admission records, course records, pre-operation discussion records, operation consent, anesthesia consent, pre-anesthesia visit records, operation safety verification records, operation inventory records, anesthesia records, operation records, post-anesthesia visit records, postoperative course records, discharge records, death records, death case discussion records, informed consent of blood transfusion treatment, and special examination (special treatment). Consultation records critical (critical) notice, pathological data, auxiliary examination report, medical imaging examination data, temperature list, doctor's advice list, and nursing records of critical (critical) patients.