Due to the progress of computer storage technology, especially CD-ROM technology, the storage capacity of electronic medical record system data can be quite huge, and the capacity of health cards carried by patients is also quite large.
Medical staff can use the electronic medical record system to store it conveniently. It is also very convenient to retrieve, browse and copy medical records, which can carry out various scientific research and statistical analysis conveniently, quickly and accurately, greatly reducing the workload of manually collecting and inputting data and greatly improving the level of clinical scientific research.
General requirements of case writing
1, medical records should be written in pen (blue or black), with clear handwriting, standardized words, fluent words, correct punctuation and neat handwriting. If there is any drug allergy, it must be marked with a red pen. The medical record shall not be altered, filled in, cut or pasted, and the doctor shall sign the full name.
2, all kinds of symptoms and signs must apply medical terms, and proverbs are not allowed.
3. All medical records shall be written in Chinese. If there is no suitable disease name or individual noun translation, the original name can be written in a foreign language. The name of the drug shall be in Chinese; The diagnosis should be filled in according to the name of the disease.
4. Simplified Chinese characters should be written according to the provisions of the Summary of Simplified Chinese Characters published by the State Council.
5. All units of measurement are legal units of measurement, and international symbols are adopted when writing.
6. Examples of date and time writing are 1989.7.30.4 or 5pm.
7, each page of medical records should fill in the patient's name, hospital number and page number. Name, gender, medical record number and date should be clearly filled in all kinds of checklists and records.
8, cancer, mental illness and other special diseases of medical records diagnosis must have a higher hospital pathological report, diagnosis certificate and related information.