Medical record writing refers to the behavior of medical staff to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and to summarize, analyze and sort out the records of medical activities.
The basic principle of medical record writing: medical record writing should be objective, true, accurate, timely and complete. ?
Time limit for writing medical records: inpatient medical records should be completed within 24 hours; The death record within 24 hours of admission shall be completed within 24 hours after the death of the patient; Due to the rescue of critically ill patients, medical records cannot be written in time, and relevant medical personnel shall truthfully record them within 6 hours after the rescue, and make records.
Extended data:
Requirements for medical record writing:
(Basis: Basic Specification for Medical Record Writing)
Article 11 The contents of outpatient (emergency) medical records include the first page of outpatient (emergency) medical records (the cover of outpatient (emergency) medical manual), medical records, laboratory tests (inspection reports), medical imaging examination materials, etc.
Twelfth outpatient (emergency) medical records should include the patient's name, gender, date of birth, nationality, marital status, occupation, work unit, address, drug allergy history and other items.
The cover content of outpatient manual should include the patient's name, gender, age, work unit or address, drug allergy history and other items.
Thirteenth outpatient (emergency) medical records are divided into initial medical records and follow-up medical records.
The contents of the first medical record should include the time of seeing a doctor, the patient, chief complaint, current medical history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions and doctor's signature, etc.
The contents of the follow-up medical record should include the time of visit, the patient, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, treatment and treatment opinions, and doctor's signature.
The writing time of emergency medical records should be specific to minutes.
Fourteenth outpatient (emergency) medical records should be filled in by the attending physician in time when the patient is hospitalized.
Fifteenth emergency observation records are records of emergency patients who need to stay in hospital for observation because of their illness, focusing on the changes of their illness and the measures of diagnosis and treatment during the observation period. The records are concise and to the point, indicating the whereabouts of the patients. When rescuing critically ill patients, rescue records should be written. The writing contents and requirements of emergency outpatient medical records refer to the writing contents and requirements of inpatient medical records.
Chapter III Writing of Hospitalization Medical Records
Article 16 The contents of hospital medical records include the first page of hospital medical records, admission records, course records, operation consent, anesthesia consent, informed consent of blood transfusion treatment, consent of special examination (special treatment), notice of critical illness (severe illness), doctor's advice, auxiliary examination report, temperature list, medical imaging examination data and pathological data.
Seventeenth admission records refer to the records written by the attending physician, obtained through consultation, physical examination and auxiliary examination, and summarized and analyzed. It can be divided into admission records, readmission records or multiple admission records, admission and discharge records within 24 hours, admission and death records within 24 hours.
Admission records and readmission records should be completed within 24 hours after the patient is admitted to the hospital; Admission and discharge records within 24 hours should be completed within 24 hours after the patient is discharged, and admission and death records within 24 hours should be completed within 24 hours after the patient dies.
Article 18 Requirements and contents of admission records.
(1) The general information of patients includes name, gender, age, nationality, marital status, birthplace, occupation, admission time, recording time and medical history statement.
(2) Chief complaint refers to the main symptoms (or signs) of patients and the duration of treatment.
(three) the current medical history refers to the details of the occurrence, evolution, diagnosis and treatment of the patient's disease, which should be written in chronological order. The contents include the incidence, the characteristics and development of main symptoms, accompanying symptoms, the course of disease and the results of diagnosis and treatment after onset, changes in general conditions such as sleep and diet, and positive or negative data related to differential diagnosis.
1. Incidence: record the time, place, priority of onset, precursor symptoms, possible causes or incentives.
2. Characteristics and development of main symptoms: describe the location, nature, duration, degree, relieving or aggravating factors, evolution and development of main symptoms in order of occurrence.
3. Accompanying symptoms: record accompanying symptoms and describe the relationship between accompanying symptoms and main symptoms.
4. Diagnosis and treatment process and results since the onset: record the detailed process and effect of examination and treatment in and out of the hospital from the onset to admission. Names of drugs, diagnosis and operation provided to patients should be marked with quotation marks ("") to distinguish them.
5. General situation since the onset: briefly record the patient's mental state, sleep, appetite, defecation and weight after the onset.
Other diseases that are not closely related to this disease but still need treatment can be recorded in another paragraph after the current medical history.
(4) Past history refers to the patient's past health and illness. The contents include general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, food or drug allergy history, etc.
(5) Personal history, marriage and childbearing history, menstrual history and family history.
1. Personal history: record the birthplace and long-term residence, living habits, hobbies such as alcohol, tobacco and drugs, occupation and working conditions, contact history of industrial poisons, dust and radioactive substances, smelting and travel history.
2. Marriage and childbearing history, menstrual history: marital status, marriage age, spouse's health status, children, etc. Female patients recorded menarche age, menstrual period days, interval days, last menstruation (or amenorrhea age), menstrual flow, dysmenorrhea and delivery.
Baidu Encyclopedia-Medical Records
Baidu Encyclopedia-Basic Specification for Medical Record Writing