Department: hospitalization number: patient name: medical record writer:

Main diagnosis:

Admission time: year, month, day, examination time: year, month, day, reviewer:

Actual score:

Medical orders. (2 points)

2. Write the generic name of the drug, indicating the dosage form, dosage, dosage, ways and specific methods, and draw a diagonal line on the right side of the group drug, and write the usage on the right side of the diagonal line. (2 points)

3. The clinical application of antibacterial drugs conforms to the guiding principles. (2 points)

4. Temporary medication should not exceed 24 hours, and all kinds of inspection and therapeutic operations should be standardized. (2 points)

5. The left top box of each row is aligned and the cancellation method is correct. (1 point)

6. Write the doctor's advice for consultation, change of hospital bed, discharge, etc. (1 point)

Admission record (2 points):

1. Complete the admission record within 24 hours (2 points)

2. (2 points)

5. Current medical history: the details of the incidence, main symptom characteristics, development and changes, accompanying symptoms, diagnosis and treatment process and results, sleep and diet effects, etc., and other diseases still need to be treated, and another record should be made in chronological order. (2 points)

6. Past history: including health, disease history, infectious diseases, vaccination history, surgery, trauma, blood transfusion, drug allergy history (1 point)

7. Personal history: including birth, residence, occupation, living characteristics, tobacco and alcohol hobbies, living habits, etc. (1 point)

8. Marriage history: marriage age, health status of lover, and feelings of husband and wife.

9. Menstruation and birth history: menstruation and pregnancy. (1 point)

1. Family history: the health status, causes of death and the presence or absence of similar diseases of three generations (parents, siblings and children). (1 point)

11. Physical examination: written in order of body system and organs. (2 points)

12. Specialty information (optional medical records): Each specialty can record its special information as needed. (1 point)

13. Auxiliary examination: the examination and results related to the disease before admission and within 24 hours after admission. There are titles, dates, addresses of foreign hospitals, and contents (1 point)

14. Diagnosis: the resident writes the preliminary diagnosis, the attending physician writes the hospital diagnosis, and writes it on the right side of the lower middle line of the last line, and the revised diagnosis is written on the left side of the lower middle line of the last line by a superior doctor with or above the title of attending physician. As far as possible, it contains the cause, explanation and diagnosis of the disease. When the diagnosis is unknown, write such and such symptoms or signs to be investigated, and arrange the possible diseases below them. () Several diseases are arranged according to the main disease, concurrent disease and concomitant disease. When the diagnosis is unknown, the most likely disease is ranked first. (2 points)

15. Doctor's signature (superior doctor within the specified time) (1 point)

Course record (35 points):

1. To complete the first course record within 8 hours after admission, patients should have diagnosis, diagnosis basis, differential diagnosis and treatment plan. (5 points)

2. Daily course record: written within the time requirement consistent with the condition, including the change of the condition, the results of auxiliary examination and clinical significance, the basis for determining or correcting the diagnosis, the evaluation of curative effect, the reasons for changing the doctor's order, and the information. (8 points)

3. Rescue records with rescue orders (2 points)

4. Blood transfusion records in blood transfusion medical records (2 points)

5. Records of transfer (in) and handover (in) (2 points)

6. Department chief's ward round record (3 points)

9, preoperative discussion of complex and critical patients (2 points)

1, operation record completed within the specified time (3 points)

11, doctor's signature of course record (1 point)

12, special examination (treatment). Have routine test results or refuse to check and communicate for more than 48 hours in hospital (2 points)

2. The inspection report is pasted in a standard and complete way. (1 point)

3. There are relevant examination results before blood transfusion in the blood transfusion medical record (2 points)

Informed notification (2 points):

1. Signature confirmation of love letter for special examination and special treatment (3 points)

2. Signature confirmation of operation consent (3 points) Signature confirmation of doctor-patient communication record (notification of illness) (3 points)

4. Signature confirmation of blood transfusion consent (3 points)

5. Signature confirmation of giving up rescue, examination and treatment (2 points)

6. Signature confirmation of critically ill notice (3 points)

< (2 points)

2. Handwritten signature. (2 points)

3. The handwriting is neat and easy to recognize, and there are no more than three typos. (2 points)

4. Write and print the medical records with blue-black ink or carbon pen. The page settings are the same as the original handwritten admission records. (4 points)

5. The standards not covered in this table shall be implemented according to the requirements of the Provincial Health Department.

rectification opinions:

rectification time: before. Department Director: Business Department: Medical Quality Management Committee