Course record refers to the continuous record of the patient's condition and diagnosis and treatment process after admission record. The contents include the patient's condition change, important auxiliary examination results and clinical significance, superior doctors' rounds, consultation opinions, doctors' analysis and discussion opinions, diagnosis and treatment measures and effects, changes and reasons of doctor's orders, important matters that need to be informed to patients and their close relatives, etc.
Requirements and contents of course records:
(a) the first course record refers to the first course record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first diagnosis record include the characteristics of the case, the discussion of the proposed diagnosis (diagnosis basis and differential diagnosis), the diagnosis and treatment plan, etc.
1. Case characteristics: The characteristics of this case should be written after comprehensive analysis, induction, collation of medical history, physical examination and auxiliary examination, including positive findings and negative symptoms and signs with differential diagnosis significance.
2. Quasi-diagnosis discussion (diagnosis basis and differential diagnosis): according to the characteristics of the case, put forward the preliminary diagnosis and diagnosis basis; Write differential diagnosis and analyze unknown diagnosis; And analyze the next diagnosis and treatment measures.
3. Diagnosis and treatment plan: put forward specific examination and treatment measures.
(two) the daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by the attending physician, but also by the internship or trainee medical staff, but should be signed by the attending physician. When writing the daily course record, first indicate the recording time, and write another line for the specific content. For critically ill patients, the course of the disease should be recorded at any time according to the change of the condition, at least/kloc-0 times a 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.
(3) The records of superior doctors' rounds refer to the records of patients' condition, diagnosis, differential diagnosis, curative effect analysis of current treatment measures and opinions on the next diagnosis and treatment.
The attending physician's first round of rounds should be completed within 48 hours after the patient is admitted to the hospital. The contents include name, professional and technical position, supplementary medical history and signs, diagnosis basis, differential diagnosis and treatment plan, etc.
The time interval of the attending physician's daily rounds is determined according to the condition and diagnosis and treatment, including the name of the attending physician, professional and technical positions, condition analysis and diagnosis and treatment opinions.
The records of ward rounds of doctors with professional and technical positions or above, including the names of ward rounds doctors, professional and technical positions, illness analysis, diagnosis and treatment opinions, etc.
(4) The discussion record of difficult cases refers to the record presided over by the director of the department or a physician with professional and technical qualifications above the deputy chief physician, and convened relevant medical personnel to discuss cases with difficult diagnosis or uncertain curative effect. The contents include the date of discussion, the moderator, the names and professional and technical positions of the participants, the specific discussion opinions and the moderator's summary opinions.
(5) The shift (pick-up) record refers to the record that the shift doctor and the succession doctor briefly summarize the patient's condition and diagnosis and treatment respectively when the patient's attending doctor changes. The log record shall be filled in by the log doctor before the log; The shift record shall be completed by the shift doctor within 24 hours after the shift. The contents of the handover record include admission date, handover or handover, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in handover or handover diagnosis and treatment scheme, and doctor's signature, etc.
(6) The record of changing majors refers to the records written by the doctors in the transfer-out department and the transfer-in department respectively after the patient needs to change majors during hospitalization and agrees to receive them. Include a transfer-out record and a transfer-in record. The transfer-out record is written by the doctor in the transfer-out department before the patient is transferred out of the department (except for emergency); The transfer-in record should be completed by the doctor in the transfer-in department within 24 hours after the patient is transferred. The record of changing major includes admission date, transfer-out or transfer-in date, transfer-out and transfer-in department, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in changing major or transferring to diagnosis and treatment scheme, and doctor's signature.
(seven) stage summary refers to the patient's hospitalization time is longer, and the monthly summary of the condition and diagnosis and treatment made by the attending physician. The contents of the stage summary include admission date, summary date, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, doctor's signature, etc.
Changes in handover (pick-up) records and main records can replace stage summary.
(eight) the rescue record refers to the record made when the patient is in critical condition and takes rescue measures. If the medical records cannot be written in time due to the rescue of critically ill patients, the relevant medical personnel shall make up the facts within 6 hours after the rescue and make records. The contents include the change of illness, the time and measures of rescue, the names and titles of medical personnel involved in rescue, etc. Record the rescue time to the minute.
(9) Invasive diagnosis and treatment operation records refer to records of various diagnosis and treatment operations (such as thoracic puncture and abdominal puncture, etc.). ) in the process of clinical diagnosis and treatment. You should write immediately after the operation is completed. The contents include the name of the operation, the operation time, the operation steps, the results and the general situation of the patient, whether the recording process is smooth, whether there are any adverse reactions, matters needing attention after the operation, whether to explain to the patient, and the signature of the surgeon.
(ten) consultation records (including consultation opinions) refers to the records written by the applicant and the consultant respectively when the patient needs the assistance of other departments or other medical institutions during hospitalization. Consultation records should be written on a separate page. The contents include application for consultation records and consultation opinions records. The record of application for consultation shall briefly explain the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and shall be signed by the consultant. Regular consultation opinions should be recorded by the consultant within 48 hours after the consultation application is issued. In case of emergency consultation, the consultant should be present within 10 minutes after the consultation application is issued, and the consultation record should be completed immediately after the consultation. The consultation record includes the consultation opinions, the name of the department or medical institution where the consultant works, the consultation time, the signature of the consultant, etc. The applicant for consultation should record the implementation of the consultation in the course record.
(eleven) preoperative summary refers to the attending physician's summary of the patient's condition before operation. The contents include the brief illness, preoperative diagnosis, surgical indications, the name and method of the operation to be performed, the anesthesia method to be performed, matters needing attention, and the patient's relevant information recorded before operation.
(12) Preoperative discussion record refers to the discussion on the proposed operation mode, possible problems during operation and countermeasures under the auspices of the superior doctor before operation due to the patient's serious illness or difficulty in operation. The contents of the discussion include preoperative preparation, surgical indications, surgical plan, possible accidents and preventive measures, names and professional and technical positions of participants, specific discussion opinions and summary opinions of the host, discussion date, signature of the recorder, etc.
(13) Preoperative interview records refer to the records of risk assessment of anesthesia to be performed by anesthesiologists before anesthesia. Visit before anesthesia can set up a separate page or record the course of disease. The contents include name, sex, age, subjects, medical record number, general situation of patients, brief medical history, auxiliary examination results related to anesthesia, planned operation mode, planned anesthesia mode, anesthesia indications and anesthesia precautions, preoperative anesthesia doctor's orders, and the date signed by anesthesiologists.
(14) Anesthesia record refers to the record of anesthesia process and treatment measures written by anesthesiologists during anesthesia implementation. Anesthesia records should be written on a separate page, including the general situation of patients, special circumstances before anesthesia, medication before anesthesia, preoperative diagnosis, intraoperative diagnosis, operation mode and date, anesthesia mode, anesthesia induction and the start and end time of various operations, the name, mode and dosage of medication during anesthesia, special or unexpected circumstances and treatment during anesthesia, operation start and end time, and the signature of anesthesiologist.
(fifteen) the operation record refers to the special record written by the operator to reflect the general situation of the operation, the operation process, the findings and handling during the operation, and shall be completed within 24 hours after the operation. Under special circumstances, when written by the first assistant, it should be signed by the operator. The operation record should be written on a separate page, including general items (patient's name, gender, department, ward, bed number, inpatient medical record number or medical record number), operation date, preoperative diagnosis, intraoperative diagnosis, operation name, operator's and assistant's name, anesthesia method, operation process, intraoperative situation and treatment, etc.
(16) Operation safety verification records refer to the records made by surgeons, anesthesiologists and visiting nurses before anesthesia, before surgery and before the patient leaves the room, * * * to check the patient's identity, operation site, operation mode, anesthesia and operation risks, and inventory of items used in the operation. , and should also check the blood type and blood consumption of blood transfusion patients. There should be a tripartite inspection, confirmation and signature by the surgeon, anesthesiologist and visiting nurse.
(seventeen) the operation inventory record refers to the records of blood, instruments and dressings used by the visiting nurses during the operation, which should be completed immediately after the operation. The operation inventory record should be written on a separate page, including the patient's name, hospital medical record number (or medical record number), operation date, operation name, inventory check of the number of various instruments and dressings used in the operation, signature of visiting nurses and surgical instrument nurses, etc.
(eighteen) the first postoperative course record refers to the course record completed by the doctors who participated in the operation immediately after the operation. The contents include operation time, intraoperative diagnosis, anesthesia mode, operation mode, brief operation flow, postoperative treatment measures and matters needing special attention after operation.
(19) Post-anesthesia interview record refers to the record of the anesthesiologist visiting the patient's anesthesia recovery after anesthesia. Post-anesthesia visits can be set up on a separate page or recorded in the course of the disease. The contents include name, sex, age, subject, medical record number, general situation of patients, recovery from anesthesia, waking time, postoperative doctor's advice, whether to remove tracheal intubation, etc. If there are special circumstances, detailed records should be made, and the date should be signed by the anesthesiologist.
(twenty) the discharge record refers to the summary of the diagnosis and treatment of the patient during the hospitalization period by the attending physician, which should be completed within 24 hours after the patient is discharged. The contents mainly include admission date, discharge date, admission situation, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge situation, discharge orders, doctor's signature, etc.
(twenty-one) the death record refers to the record of the diagnosis, treatment and rescue of the deceased patient by the attending physician during his hospitalization, which shall be completed within 24 hours after the death of the patient. The contents include admission date, death time, admission situation, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of illness and rescue process), cause of death, death diagnosis and so on. Record the time of death to the minute.
(twenty-two) the discussion record of death cases refers to the discussion and analysis record of death cases presided over by the director of the department or a doctor with professional and technical qualifications above the deputy chief physician within one week of the patient's death. The contents include the date of discussion, the names of the moderator and participants, professional and technical positions, specific discussion opinions and moderator's summary opinions, and the signature of the recorder.
(twenty-three) the nursing record of patients with severe (critical) illness refers to the objective record of the nursing process of patients with severe (critical) illness during hospitalization according to the doctor's advice and illness. Nursing records of critically ill patients should be written according to the nursing characteristics of corresponding specialties. The contents include the patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other observations, nursing measures and effects, and nurse's signature. The recording time should be accurate to the minute.
Legal basis:
Notice of the National Health and Family Planning Commission and state administration of traditional chinese medicine on Printing and Distributing the Regulations on Medical Records Management of Medical Institutions (20 13 Edition)
Article 2 Medical records refer to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records. Form a medical record after filing.
Article 4 According to the different forms of medical records, it can be divided into paper medical records and electronic medical records. Electronic medical records have the same effect as paper medical records.
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