A Brief Introduction to the New Basic Specification for Medical Record Writing
The standard of the new Basic Specification for Medical Record Writing requires that medical record writing should be objective, true, accurate, timely, complete and standardized. Medical records should be written in Chinese, and commonly used abbreviations in foreign languages and names of symptoms, signs and diseases without official Chinese translation can be written in foreign languages. At the same time, when there are typos in the process of writing medical records, they should be marked with double lines to keep the original records clear and readable, and indicate the time of revision, which should be signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting. Medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel registered in the hospital. The contents and starting and ending time of medical orders shall be written by doctors. The doctor's advice cannot be changed. When cancellation is required, the word "cancellation" should be marked with red ink and signed. In order to respect the patient's right to know, the Code clearly stipulates that for medical activities that require the patient's written consent, the informed consent should be signed by the patient himself, and in the case that the patient does not have full capacity for civil conduct, it should be signed by his legal representative; When the patient is unable to sign due to illness, it shall be signed by the person authorized by him; At the same time, the standard also stipulates that in order to rescue patients, hospitals can sign informed consent forms on behalf of patients if legal representatives or authorized persons cannot sign them in time.