(2) All records must be carefully written in accordance with the regulations, requiring complete and true contents, concise sentences, prominent points, clear levels, clear handwriting, no out-of-line words, and no arbitrary deletion or supplement.
(3) Simplified Chinese characters should be written according to the regulations published by the State Council, and they should not be invented to avoid typos.
(4) The names and codes of disease diagnosis and operation shall be written according to the International Classification of Diseases (ICD-9). Translation should be based on China Medical Vocabulary published by People's Health Publishing House. Individual nouns such as disease names have not been properly translated, and their original names can be written in foreign languages. Drug names can be in Chinese, English or Latin, but chemical molecular formulas are not allowed.
(5) All records must have a complete date and be filled in the order of "year, month and day" (e.g.1991.1.27). If necessary, the time should be marked in the form of "hour, minute, morning and afternoon", or Am in the morning, Pm in the afternoon, 12N at noon and 12MN at midnight.
(6) At the end of each record, you must sign the full name or affix the specified seal, and make it clear and easy to recognize.
(7) The unit of measurement must be the legal unit of measurement.
(8) All records written by interns, advanced doctors and residents must be reviewed by their superior doctors, modified and supplemented as necessary, and signed. All amendments and signatures should be made in red ink. Too many changes (more than 5 per page) should be copied in time.
On the basis of a comprehensive understanding of the illness, the superior doctor who wrote the inpatient medical record may not write it on the hospitalization record after carefully modifying the signature to show responsibility, but must carefully write the first course record. The admission record written by the resident should be revised by the attending physician or above. The revision of hospital medical records or admission records by superior doctors should be completed within 72 hours at the latest.
Legal basis: Article 9 of the Regulations on Handling Medical Accidents clearly stipulates that it is strictly forbidden to alter or forge medical records. The identification of the authenticity of medical records is the most important aspect of whether medical records can be used as important documentary evidence.