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.

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. The writing of medical records in medical institutions includes both the content of the medical records and the writing form. As early as 2002, our country's law made clear legal provisions on the writing of medical records. The writing of medical records in medical institutions must comply with the following regulations: First, the writing content of the medical records. Medical record writing should be objective, true, accurate, timely and complete. The four regulations of objectivity, authenticity, accuracy, and timeliness are designed to ensure the objective and truthful content of medical records, and medical institutions are strictly prohibited from altering or forging medical records. If a medical institution alters or falsifies medical records, the altered or forged parts will be invalid and will be handled in a manner that is beneficial to the patient. The completeness of medical records means that medical records must contain specified items. Except for incompleteness caused by patient reasons, medical institutions will bear adverse consequences for incomplete medical records. Medical records consist of outpatient (emergency) medical records and inpatient medical records. The contents of outpatient (emergency) medical records include the homepage of outpatient medical records (cover of outpatient manual), medical records, laboratory test orders (test reports), medical imaging examination data, etc. The first page of outpatient (emergency) medical records should include the patient’s name, gender, date of birth, ethnicity, marital status, occupation, workplace, address, drug allergy history, etc. The cover content of the outpatient manual should include the patient's name, gender, age, work unit or address, drug allergy history, etc. Outpatient (emergency) clinic 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. Outpatient (emergency) medical record records should be completed by the attending physician in a timely manner when the patient sees the patient. When rescuing critically ill patients, rescue records should be written. For patients admitted to the emergency observation room, observation records during their stay should be written. Inpatient medical records include the home page of the inpatient medical record, hospitalization log, temperature sheet, doctor's order, laboratory test report (test report), medical imaging examination data, special examination (treatment) consent form, surgery consent form, anesthesia record sheet, surgery and surgical care records Documents, pathology data, nursing records, discharge records (or death records), disease course records (including rescue records), difficult case discussion records, consultation opinions, superior physician’s ward rounds records, death case discussion records, etc. Each of the above items has its own constituent elements and recording requirements. You must write as required, otherwise you will have to bear adverse consequences.

Secondly, the writing form of medical records. Inpatient medical records should be written with blue-black ink or carbon ink. Outpatient (emergency) medical records and materials that need to be copied can be written with blue or black oil-and-water ballpoint pens. If any violation of this provision affects the ascertainment of facts, medical institutions shall bear adverse consequences. Medical records should be written neatly, with clear handwriting, accurate expressions, smooth sentences and correct punctuation. When a typo occurs during writing, double lines should be used to draw on the typo, and methods such as scraping, gluing, and painting should not be used to cover up or remove the original writing. If there is a violation of the regulations, we believe that the part that has been covered up or removed and overwritten is invalid, except for the part that is beneficial to the patient; if it is covered up or removed and overwritten, it will be handled in accordance with the principle of benefiting the patient based on the specific content of the medical record. 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. Violation of regulations and evidence proving overdue records shall be deemed not to have been recorded and shall be dealt with in a manner favorable to the patient. Medical institutions must comply with the above regulations when writing medical records, otherwise they will bear adverse consequences.