(2) The writing of medical records should be smooth and concise, with clear handwriting, no typos, self-made words and non-international abbreviations in Chinese and English. Numbers in words and expressions are written in Arabic numerals. Nothing in the medical record is allowed to be modified. If there is any blank after the course record, it is required to mark it with diagonal lines, and no other content can be added.
(three), medical record writing content requirements are true and complete, focused, clear, logical and scientific, comprehensive analysis and discussion opinions. It is required to write medical records in Chinese medical terms.
(4), admission records or medical records should be completed within 24 hours after the patient was admitted to the hospital. For patients who have been admitted to our hospital for many times, the X-th admission record can be written; For patients discharged within 24 hours after admission, the discharge record can be written in the same format as the discharge record. The first course record requires residents to complete it in time; The first course record after operation was completed immediately by the resident who participated in the operation.
(5) Admission records, first visit records, stage summary, handover records, rescue records, death records and death discussions must be written by residents (interns are not qualified to write); In principle, the operation record should be written by the first operator. If there are special circumstances, it can be written by the first assistant, but it must be signed by the first operator after review. All the records written by interns, such as hospitalization records, course records, discharge records, etc., must be reviewed by their superior doctors, made necessary amendments and supplements, and signed. Death records and death discussions must be signed by residents and attending physicians.
(6), hematuria and stool three routine; Those who have been hospitalized in the internal medicine system for more than two days require all three examinations; The surgical system requires at least routine blood and urine tests. As for routine stool examination, it depends on the condition as appropriate, and the results of blood, urine and stool examination recently examined by outpatient department (generally within one week according to the condition) can also be copied as appropriate. The test sheet should be attached to the test label for reference. The internal medicine system should have an inspection record sheet for routine examination of hematuria and stool. All inspection and laboratory report forms should be marked with date and project name. Normal ones should be marked with blue-black ink pen, and abnormal ones should be marked with red ink pen or ballpoint pen. When labeling, the initials should be aligned up and down with a word in the middle.
(seven), check whether all kinds of imaging and special inspection reports are complete before discharge; Those who lack try to find a way to make up for it.
(8) All infectious diseases cannot be missed. For example, for those with abnormal liver function, the test report of antibodies against hepatitis B, hepatitis C, hepatitis A or hepatitis E should be recovered, and for those who are suspected of hepatitis or can diagnose a certain type of hepatitis, the infectious disease card should be reported in time. If the single transaminase is high, those related to the disease or drug treatment should be analyzed, and noted in the course record and discharge record, and the infectious disease card can not be reported.
(9) Death discussion: presided over by the attending physician in the ward, every death case will be discussed with the lower-level doctors, focusing on the diagnosis and causes of death, and at the same time, we should learn lessons. Controversial cases can be extended to the whole ward medical staff to participate in the discussion under the leadership of the director. Records of discussions must be kept in medical records. There should be deposits in the department for future reference.
(10), all kinds of trauma examination and treatment, surgery, blood transfusion and self-funded drug use, etc. , require the signature of the patient or the person entrusted by the patient to start.
(eleven), the form included in the medical record needs to be discussed by experts in the corresponding professional disciplines to develop a national unified form format for trial implementation.
(twelve), the medical records of traditional Chinese medicine are written according to the requirements of the "Standard of Chinese Medical Records" issued by state administration of traditional chinese medicine.