Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages. Medical record writing should be neat, clear, accurate, fluent and punctuated correctly.

When typos appear in the writing process, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting. Medical records should be written in accordance with the regulations and signed by the corresponding medical personnel.

Medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution. Medical personnel receiving continuing education should write medical records after being approved by medical institutions receiving continuing education according to their actual qualifications for professional work.

The superior medical staff has the responsibility to review and modify the medical records written by the lower medical staff. When modifying, the date of modification shall be indicated, and the signature of the modifier shall be clear and readable.

If the medical records cannot be written in time due to the rescue of critically ill patients, the relevant medical personnel shall make up the facts within 6 hours after the rescue and make records. Carry out medical activities (such as special examination, special treatment, surgery, experimental clinical treatment, etc.). If the patient's written consent is required according to relevant regulations, the consent form shall be signed by the patient himself.

When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; If the patient is unable to sign due to illness, it shall be signed by his close relatives; if there are no close relatives, it shall be signed by his related person; In order to rescue patients, if the legal representative or close relatives or related parties cannot sign in time, the person in charge of the medical institution or the authorized person in charge may sign.

If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's close relatives shall be informed of the relevant situation, and the close relatives of the patient shall sign the consent form and record it in time. If the patient has no close relatives or the patient's close relatives are unable to sign the consent form, the consent form shall be signed by the patient's legal representative or relevant person.