The Ministry of Health revised the basic standards for writing medical records (full text) China News Service, February 4th (Xinhua) The website of the Ministry of Health issued a notice today requiring that starting from March 1, 2010, the Ministry of Health will revise the basic standards for writing medical records. Medical institutions shall implement the revised and improved "Basic Standards for Writing Medical Records", and the "Basic Standards for Writing Medical Records (Trial)" promulgated in 2002 (Weiyifa [2002] No. 190) will be abolished at the same time. Basic Standards for Writing Medical Records Chapter 1 Basic Requirements Article 1 Medical records refer to the sum of text, symbols, charts, images, slices and other data generated by medical staff during medical activities, including outpatient (emergency) medical records and inpatient medical records. Article 2 Medical record writing refers to the behavior of medical personnel obtaining relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment, and nursing, and summarizing, analyzing, and organizing to form medical activity records. Article 3 Medical record writing must be objective, true, accurate, timely, complete and standardized. Article 4 Medical records should be written using blue-black ink or carbon ink. Medical records that need to be copied can be written with blue or black oil-and-water ballpoint pens. Computer-printed medical records should meet the requirements for medical record preservation. Article 5 Medical records shall be written in Chinese. Common foreign language abbreviations and symptoms, signs, disease names without official Chinese translations, etc. may be written in foreign languages. Article 6 Medical terminology should be used in standardized writing of medical records, with neat writing, clear handwriting, accurate expressions, smooth sentences and correct punctuation. Article 7 When a typo occurs during the writing process of the medical record, the typo should be marked with a double line, the original record should be kept clear and legible, the time of modification should be noted, and the signature of the person who modified it should be noted. Do not use scraping, sticking, painting or other methods to cover up or remove the original writing. Superior medical staff have the responsibility to review and modify medical records written by subordinate medical staff. Article 8 Medical records shall be written in accordance with the prescribed contents and signed by the corresponding medical personnel. Medical records written by intern medical personnel and probationary medical personnel must be reviewed, modified and signed by medical personnel registered in the medical institution. Medical personnel who are in training shall write medical records after being determined by the medical institution based on their actual ability to work in this profession. Article 9 When writing medical records, Arabic numerals must be used to write dates and times, and the 24-hour format should be used for recording. Article 10 For medical activities that require the written consent of the patient, the patient shall sign an informed consent form. When the patient does not have full capacity for civil conduct, his or her legal representative shall sign; when the patient is unable to sign due to illness, his or her authorized person shall sign; in order to rescue the patient, when the legal representative or authorized person is unable to sign in time , which can be signed by the person in charge of the medical institution or the authorized person in charge. If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's close relatives should be informed of the relevant situation, and the patient's close relatives should sign an informed consent form and record it in a timely manner. If the patient has no close relatives or if the patient's close relatives are unable to sign the consent form, the patient's legal representative or related person shall sign the consent form. Chapter 2 Contents and Requirements for Outpatient (Emergency) Clinic Medical Records Article 11 The contents of outpatient (emergency) clinic medical records include the first page of outpatient (emergency) clinic medical records (cover of outpatient (emergency) clinic manual), medical records, laboratory test orders (test reports) ), medical imaging examination data, etc. Article 12 The first page of outpatient (emergency) medical records shall include the patient’s name, gender, date of birth, ethnicity, marital status, occupation, workplace, address, drug allergy history and other items. The cover content of the outpatient manual should include the patient's name, gender, age, work unit or address, drug allergy history, etc. Article 13: Outpatient (emergency) medical records are divided into initial medical records and follow-up medical records. The written content of the initial medical record should include the time of visit, department, chief complaint, current history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions, and physician signature, etc. The written content of follow-up medical records should include the time of visit, department, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, treatment opinions and physician's signature, etc. The time of consultation should be written down to the minute in the emergency medical record. Article 14: Outpatient (emergency) medical record records shall be completed by the treating physician in a timely manner when the patient is treated.

Article 15 The emergency observation record is a record of emergency patients who need to be hospitalized for observation due to their condition. It focuses on recording the changes in condition and diagnosis and treatment measures during the observation period. The record is concise and concise, and the whereabouts of the patient are indicated. When rescuing critically ill patients, rescue records should be written. The content and requirements for writing rescue records in outpatient (emergency) clinics shall be based on the content and requirements for writing rescue records in inpatient medical records. Chapter 3 Contents and Requirements for Writing Inpatient Medical Records Article 16 The content of inpatient medical records includes the first page of the inpatient medical record, admission record, disease course record, operation consent form, anesthesia consent form, blood transfusion treatment informed consent form, special examination (special treatment) consent form, Critical illness (serious) notice, doctor's order, auxiliary examination report, body temperature sheet, medical imaging examination data, pathology data, etc. Article 17 Admission records refer to records written by treating physicians who obtain relevant information through consultation, physical examination, and auxiliary examination after the patient is admitted to the hospital, and summarize and analyze the information. It can be divided into admission records, re- or multiple admission records, admission and discharge records within 24 hours, and admission death records within 24 hours. Admission records, readmission or multiple admission records should be completed within 24 hours after the patient is admitted; admission and discharge records within 24 hours should be completed within 24 hours after the patient is discharged, and admission death records within 24 hours should be completed within 24 hours after the patient's death. . Article 18 Requirements and contents of admission records. (1) The patient’s general information includes name, gender, age, ethnicity, marital status, place of birth, occupation, admission time, recording time, and person stating the medical history. (2) Chief complaint refers to the main symptoms (or signs) and duration that prompt the patient to seek medical treatment. (3) The history of current illness refers to the patient’s detailed information on the occurrence, evolution, diagnosis and treatment of the disease, and should be written in chronological order. The content includes the onset, main symptom characteristics and their development and changes, accompanying symptoms, diagnosis and treatment process and results after the onset, changes in general conditions such as sleep and diet, as well as positive or negative data related to differential diagnosis, etc. 1. Incidence: record the time, place, onset, prodromal symptoms, possible causes or incentives. 2. Characteristics of main symptoms and their development and changes: Describe the location, nature, duration, degree, mitigating or exacerbating factors, and evolution of the main symptoms in the order of occurrence. 3. Accompanying symptoms: Record the accompanying symptoms and describe the relationship between the accompanying symptoms and the main symptoms. 4. The diagnosis and treatment process and results since the onset of the disease: record the detailed process and results of the patient's examination and treatment in and outside the hospital from the onset of the disease to before admission. The name of the drug, diagnosis and procedure provided by the patient must be distinguished by quotation marks (""). 5. General situation since the onset of the disease: Briefly record the patient's mental state, sleep, appetite, urine and feces, weight, etc. since the onset of the disease. Other diseases that are not closely related to the current disease but still require treatment can be recorded in a separate paragraph after the current history. (4) Past history refers to the patient’s past health and disease conditions. The content includes past general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, food or drug allergy history, etc. (5) Personal history, marriage and childbirth history, menstrual history, and family history. 1. Personal history: Record the place of birth and long-term residence, living habits and hobbies such as smoking, alcohol, and drugs, occupation and working conditions, and whether there is a history of exposure to industrial poisons, dust, radioactive substances, and whether there is a history of metallurgy and travel. 2. Marital and childbearing history, menstrual history: marital status, age at marriage, spouse’s health status, whether there are children, etc. Female patients record the age of menarche, number of menstrual periods, number of days between periods, time of last menstruation (or age of amenorrhea), menstrual volume, dysmenorrhea and fertility. 3. Family history: the health status of parents, brothers, and sisters, whether there are similar diseases to the patient, and whether there are any diseases that are inherited in the family. (6) The physical examination should be written in a systematic and orderly manner. Content includes body temperature, pulse, respiration, blood pressure, general condition, skin, mucous membranes, superficial lymph nodes throughout the body, head and its organs, neck, chest (thoracic cage, lungs, heart, blood vessels), abdomen (liver, spleen, etc.) , rectum and anus, external genitalia, spine, limbs, nervous system, etc. (7) Special circumstances of the specialty The special circumstances of the specialty should be recorded according to the needs of the specialty. (8) Auxiliary examination refers to the main examination related to the disease and its results performed before admission.

(5) Handover (succession) records refer to records in which the switching physician and the succeeding physician respectively briefly summarize the patient's condition and diagnosis and treatment when the patient's treating physician changes. The shift handover record should be written and completed by the switching physician before the shift is handed over; the shift succession record should be completed by the succeeding physician within 24 hours after the shift is taken over. The content of the handover (succession) record includes the date of admission, date of handover or succession, patient name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, handover precautions or succession diagnosis and treatment plan, physician Signature etc. (6) Transfer records refer to records written by the doctors of the transferring department and the transferring department respectively when a patient needs to be transferred to another department during his hospitalization, after consultation with the transferring department doctor and consent to accept the patient. Includes transfer-out records and transfer-in records. The transfer-out record shall be written by the physician of the transferring department before the patient is transferred out of the department (except in emergencies); the transfer-in record shall be completed by the physician of the transferring department within 24 hours after the patient is transferred in. The contents of the transfer record include the date of admission, the date of transfer out or in, the department transferred out and transferred into, the patient's name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, transferred subjects and Notes or transferred to the diagnosis and treatment plan, physician signature, etc. (7) Stage summary refers to a monthly summary of the patient's condition, diagnosis and treatment made by the treating physician when the patient has been hospitalized for a long time. The contents of the stage summary include admission date, summary date, patient name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, physician signature, etc. Class handover records and department transfer records can replace the stage summary. (8) Rescue record refers to the record made when the patient is in critical condition and rescue measures are taken. If they fail to write down medical records in time due to rescuing critical patients, the relevant medical staff should make up the actual records within 6 hours after the end of the rescue and make an annotation. The content includes changes in the condition, rescue time and measures, names and professional and technical titles of medical personnel participating in the rescue, etc. The rescue time should be recorded down to the minute. (9) Invasive diagnosis and treatment operation records refer to records of various diagnostic and therapeutic operations (such as thoracentesis, abdominal puncture, etc.) performed during clinical diagnosis and treatment activities. It should be written immediately after the operation is completed. The content includes the name of the operation, operation time, operation steps, results and the general condition of the patient, recording whether the process went smoothly and whether there were any adverse reactions, postoperative precautions and whether they were explained to the patient, and the signature of the operating physician. (10) Consultation records (including consultation opinions) refer to the records written by the applicant physician and the consulting physician respectively when the patient requires assistance from other departments or other medical institutions for diagnosis and treatment during hospitalization. The consultation record should be written on a separate page. The content includes application consultation records and consultation opinion records. The record of application for consultation should briefly state the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and the signature of the physician applying for consultation, etc. The recording of routine consultation opinions should be completed by the consulting physician within 48 hours after the consultation application is issued. In the case of emergency consultation, the consulting physician should be present within 10 minutes after the consultation application is issued, and complete the consultation record immediately after the consultation ends. The content of the consultation record includes the consultation opinions, the department of the consulting physician or the name of the medical institution, the consultation time, and the signature of the consulting physician, etc. The physician applying for consultation should record the implementation of consultation opinions in the disease course record. (11) Preoperative summary refers to the summary of the patient's condition made by the treating physician before surgery. The content includes a brief medical condition, preoperative diagnosis, surgical indications, name and method of the planned operation, planned anesthesia method, precautions, and records of the operator's preoperative inspection of the patient, etc. (12) Preoperative discussion record refers to the discussion on the proposed surgical method and possible problems and countermeasures that may arise during the operation under the auspices of the superior physician before the operation due to the serious condition of the patient or the difficulty of the operation. The discussion content includes preoperative preparations, surgical indications, surgical plans, possible accidents and preventive measures, names and professional and technical positions of participants, specific discussion opinions and summary comments of the moderator, discussion date, signature of the recorder, etc. . (13) Anesthesia preoperative visit record refers to the record in which the anesthesiologist conducts a risk assessment on the patient before anesthesia is administered. The pre-anesthesia visit can be kept on a separate page or recorded during the course of the disease.

The content includes name, gender, age, department, medical record number, general situation of the patient, brief medical history, auxiliary examination results related to anesthesia, planned surgical method, planned anesthesia method, anesthesia indications and issues that need to be paid attention to during anesthesia, Preoperative anesthesia orders, signed by the anesthesiologist and filled in with the date. (14) Anesthesia records refer to the records of the anesthesia process and treatment measures written by the anesthesiologist during the implementation of anesthesia. The anesthesia record should be written on a separate page, including the patient's general condition, special preoperative conditions, pre-anesthetic medication, preoperative diagnosis, intraoperative diagnosis, surgical method and date, anesthesia method, anesthesia induction and the start and end time of each operation, anesthesia The names, methods and dosages of medications used during the period, special or emergency situations and their handling during anesthesia, the start and end time of the operation, signature of the anesthesiologist, etc. (15) Operation records refer to special records written by the operator that reflect the general conditions of the operation, the operation process, intraoperative findings and treatment, etc., and should be completed within 24 hours after the operation. In special circumstances, when written by the first assistant, it should be signed by the surgeon. The surgical record should be written on a separate page, including general items (patient name, gender, department, ward, bed number, hospitalization record number or case number), date of surgery, preoperative diagnosis, intraoperative diagnosis, name of the surgery, operator and Assistant’s name, anesthesia method, operation process, intraoperative conditions and treatment, etc. (16) Surgical safety verification record means that the surgeon, anesthesiologist and circulating nurse jointly review the patient’s identity, surgical site, surgical method, and anesthesia before the anesthesia is administered, before the operation begins, and before the patient leaves the room. and records for verification of surgical risks, inventory of surgical items, etc. Blood transfusion patients should also check blood type and blood volume. It should be checked, confirmed and signed by the operating surgeon, anesthesiologist and circulating nurse. (17) Operation inventory record refers to the roving nurse's record of blood, instruments, dressings, etc. used by surgical patients during the operation, which should be completed immediately after the operation. The surgical inventory record should be written on a separate page, including the patient's name, hospitalization record number (or medical record number), operation date, operation name, inventory and verification of the number of various instruments and dressings used during the operation, signatures of the circulating nurse and the surgical instrument nurse, etc. (18) The first post-operative course record refers to the course record completed by the physician participating in the operation immediately after the patient's surgery. The content includes operation time, intraoperative diagnosis, anesthesia method, surgical method, brief operation process, postoperative treatment measures, matters that should be paid special attention to after operation, etc. (19) Post-anesthesia visit record refers to the record of the anesthesiologist’s visit to the patient’s recovery from anesthesia after the anesthesia is administered. Post-anesthesia visits can be kept on a separate page or recorded during the course of the disease. The content includes name, gender, age, department, medical record number, general situation of the patient, recovery from anesthesia, waking time, postoperative medical instructions, whether to remove the tracheal intubation, etc. If there are special circumstances, it should be recorded in detail, signed by the anesthesiologist and filled in with the date. . (20) The discharge record refers to the treating physician's summary of the patient's diagnosis and treatment during the hospitalization, which should be completed within 24 hours after the patient is discharged. The content mainly includes admission date, discharge date, admission status, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge status, discharge medical order, physician signature, etc. (21) Death record refers to the treating physician’s record of the diagnosis, treatment and rescue process of the deceased patient during his hospitalization, which should be completed within 24 hours after the patient’s death. The content includes the date of admission, time of death, admission status, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of the condition and the rescue process), cause of death, death diagnosis, etc. Time of death should be recorded down to the minute. (22) Death case discussion records refer to records of discussion and analysis of death cases within one week of the patient's death, presided over by the department director or a physician with professional and technical qualifications above deputy chief physician. The content includes the date of discussion, names of moderators and participants, professional and technical positions, specific discussion opinions and summary comments of the moderator, signature of the recorder, etc. (23) Nursing records for seriously ill (critically ill) patients refer to the objective records of the nursing process of seriously ill (critically ill) patients during their hospitalization by nurses based on medical orders and conditions. Nursing records for seriously ill (critically ill) patients should be written according to the nursing characteristics of the corresponding specialty.

The content includes the patient's name, department, hospital record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other condition observations, nursing measures and effects, nurse signature, etc. . Recording times should be specified to the minute. Article 23 The surgical consent form refers to a medical document in which the treating physician informs the patient of the proposed surgery before surgery and the patient signs whether he or she agrees to the surgery. The content includes preoperative diagnosis, name of the operation, complications that may occur during or after the operation, surgical risks, patient opinions and signatures, signatures of the treating physician and operator, etc. Article 24 An anesthesia consent letter refers to a medical document in which the anesthesiologist informs the patient of the relevant circumstances of the proposed anesthesia before anesthesia, and the patient signs whether he or she agrees with the anesthesia opinion. The content includes the patient’s name, gender, age, medical record number, department, preoperative diagnosis, planned surgical method, planned anesthesia method, the patient’s basic diseases and special conditions that may affect anesthesia, and invasive operations planned during anesthesia. and monitoring, anesthesia risks, possible complications and accidents, the patient’s opinion and signature, and the anesthesiologist’s signature and date. Article 25 The informed consent form for blood transfusion treatment refers to a medical document in which the treating physician informs the patient of the relevant circumstances of the blood transfusion before the blood transfusion, and the patient signs whether he or she agrees to the blood transfusion. The content of the informed consent form for blood transfusion treatment includes the patient’s name, gender, age, department, medical record number, diagnosis, indication for blood transfusion, components of the blood to be transfused, relevant test results before blood transfusion, risks of blood transfusion and possible adverse consequences, and the patient’s opinions and signature , physician’s signature and date. Article 26 The consent form for special examinations and special treatments refers to a medical document in which the treating physician informs the patient of the relevant circumstances of the special examination and special treatment before the implementation of the special examination and special treatment, and the patient signs whether he agrees to the examination or treatment. . The content includes special examinations, names and purposes of special treatment items, possible complications and risks, patient signatures, physician signatures, etc. Article 27 Critical (serious) illness notification refers to a medical document in which the treating physician or the doctor on duty informs the patient's family of the patient's condition when the patient's condition is critical or serious, and is signed by the patient. The content includes the patient’s name, gender, age, department, current diagnosis and critical condition, patient’s signature, physician’s signature and date. Make two copies, one copy should be kept by the patient and the other should be kept in the medical record. Article 28 Medical orders refer to medical instructions issued by doctors in medical activities. Medical orders are divided into long-term medical orders and temporary medical orders. The content of the long-term medical order includes the patient's name, department, hospitalization record number (or medical record number), page number, start date and time, content of the long-term medical order, stop date and time, physician's signature, execution time, and execution nurse's signature. The content of the temporary medical order includes the time of the medical order, the content of the temporary medical order, the physician's signature, the execution time, the execution nurse's signature, etc. The content of the medical order and the start and stop times should be written by the physician. The contents of medical orders should be accurate and clear. Each medical order should contain only one content and indicate the time of issuance, which should be specific to the minute. Doctor's orders may not be altered. When cancellation is required, the word "Cancel" should be marked in red ink and signed. Generally, physicians are not allowed to give oral medical orders. When oral medical orders need to be given to rescue critical patients, nurses should repeat them. After the rescue, the doctor should immediately make up the medical instructions according to the facts. Article 29 The auxiliary examination report sheet refers to the record of various examinations and examination results performed during the patient's hospitalization. The content includes the patient's name, gender, age, hospitalization record number (or medical record number), examination items, examination results, report date, signature or seal of the reporting person, etc. Article 30 The temperature sheet is in table format and is mainly filled in by nurses. The content includes the patient's name, department, bed number, admission date, hospitalization record number (or medical record number), date, days after surgery, body temperature, pulse, respiration, blood pressure, stool frequency, fluid intake and output, weight, weeks of hospitalization, etc. . Chapter 4 Contents and Requirements for Printing Medical Records Article 31 Printing medical records refers to medical records that are generated and printed using word processing software (such as Word documents, WPS documents, etc.). Printed medical records shall be entered in accordance with the contents of these regulations and printed in a timely manner, and shall be handwritten and signed by the corresponding medical staff.

Article 32 Medical institutions shall use unified paper, fonts, font sizes and layout formats when printing medical records. The printed handwriting should be clear and legible, and meet the requirements for retention period and copying of medical records. Article 33 During the editing process of printed medical records, modifications shall be made in accordance with authority requirements. Medical records that have been entered, printed and signed shall not be modified. Chapter 5 Others Article 34 The first page of inpatient medical records shall be written in accordance with the provisions of the "Notice of the Ministry of Health on Revising and Issuing the First Page of Inpatient Medical Records" (Weiyifa [2001] No. 286). Article 35 Special examinations and special treatments shall be carried out in accordance with the relevant provisions of the "Implementation Rules of the Regulations on the Management of Medical Institutions" (Ministry of Health Order No. 35, 1994). Article 36 The basic standards for writing medical records of traditional Chinese medicine shall be separately formulated by the State Administration of Traditional Chinese Medicine. Article 37 The basic specifications for electronic medical records shall be formulated separately by the Ministry of Health. Article 38 These regulations will come into effect on March 1, 2010. The "Basic Standards for Writing Medical Records (Trial)" (Weiyifa [2002] No. 190) promulgated by our Ministry in 2002 will be abolished at the same time.