Section 2 Contents and Requirements for Writing Medical Records During Hospitalization

1. Admission Medical Records

General items: name, gender, chronological age, marital status, place of origin ( It is necessary to indicate the nationality, province, city and county), ethnicity, work unit, military branch, position or occupation and project, address, date of admission (time of admission should be indicated for acute or severe cases), date of medical history collection, date of medical history recording, and condition. Narrator (if it is self-reported by the patient, this item is omitted).

Chief Complaint: The most important symptoms or signs experienced by the patient and their duration (if the duration is short, the number of hours should be recorded). For example, "fever lasted for 6 days and red macules all over the body for 3 days." Suffering from several important diseases at the same time, such as pneumonia, diabetes, leukemia, etc., should be listed separately in the chief complaint.

It is not appropriate to use diagnosis or test results to replace symptoms. When there is more than one main complaint, they should be listed in order of occurrence, such as "fever, runny nose, sore throat, cough for 2 days": "many Drinking, polyphagia, polyuria, and weight loss for 5 months": "Petechiae, ecchymosis, and dizziness for 1 month": "Recurrent episodes of palpitations, shortness of breath, and edema after exertion for more than 5 years": "Urine frequency and urgency for 3 hours."

History of current illness

1. Arrange the symptoms in chronological order, accurately record the date of onset, urgency of onset, triggers of onset, the time of occurrence of each symptom and its development and change process . Negative symptoms relevant to the differential diagnosis must also be documented.

2. When describing symptoms, you should focus on the key points and seek a system. For example, when describing pain, you should clarify its location, time, nature, degree and other related factors.

3. Ask the system for accompanying symptoms to avoid missing out.

4. Past examinations and treatments.

5. For accidents, suicides, homicides and other details related to the medical condition, we should strive to record them objectively and truthfully, and no subjective speculation or comments should be made.

6. When writing the medical history of integrated traditional Chinese and Western medicine, ask about the relevant medical history according to the requirements of traditional Chinese medicine (refer to the medical record requirements of the Department of Traditional Chinese Medicine).

7. For those who suffer from multiple diseases at the same time, they can be described in sections or combined with records according to the actual situation and the convenience of description and understanding. If there are important injuries and illnesses related to other major diseases that have not healed and still need to be diagnosed and treated, they should be described in paragraphs.

Past history should record injuries and illnesses that have been suffered in the past and have been cured or have no symptoms. If there are still some symptoms, signs and lesions, they should be recorded realistically; if they are more important, Injuries and injuries should be recorded in the medical history instead.

1. General health status: healthy or weak.

2. History of acute infectious diseases and skin diseases. Record the time of disease occurrence, treatment results, and whether there are any complications in chronological order. If there is no history of infectious diseases or skin diseases, the names of infectious diseases and skin diseases that are related to the current illness but have not occurred must also be recorded in this paragraph for future reference.

3. Whether you have received vaccinations, its type, and the type and date of the most recent vaccination.

4. Ask about relevant diseases by system, including the five organs, respiratory system, circulatory system, digestive system, blood system, genitourinary system, endocrine system, metabolism, neuropsychiatric system, and motor system (muscle, bone, joints), trauma, surgery history, poisoning and drug allergies.

Personal history

1. Place of birth and experience (pay special attention to natural epidemic foci and endemic epidemic areas, and indicate the year and month of migration).

2. Living and eating habits. Tobacco and alcohol addiction.

3. Past and current occupation and work status (including joining the army or participating in work, type of work or military service, and position), and whether there is a history of exposure to dust, poisons, radioactive substances, and infectious disease patients.

4. Menstrual history from menarche to the present, menstrual cycle, menstrual period days, and age of amenorrhea can be recorded according to the following formula:

Age at menarche, number of days of menstruation per period, age of amenorrhea, and menstrual period The number of days apart is, for example: 16 3～4 48 30～32

And should record whether there is pain during menstrual cramps, the amount, color and other characteristics of each menstrual period, and the date of the last menstrual period.

5. Marriage history: date of marriage, health status of spouse; if spouse is deceased, record cause and year of death.

6. Reproductive history: Number of pregnancies and births, whether the birth was normal, and whether there is any history of premature birth or miscarriage, birth control, or sterilization.

Family history

1. The health status of the father, mother, brother, younger brother, sister, younger sister, son and daughter. If deceased, state the cause of death.

2. When you encounter a disease that is suspected to have genetic factors or life exposure factors, you should ask if there are any similar patients in the family. For important hereditary diseases, a family diagram should be drawn after full investigation.

Physical examination: Physical examination should pay attention to adequate lighting, comfortable position of the patient, and prevention of cold. The technique is required to be light and correct, with a kind attitude, and rough movements should be avoided. The examination should be carried out comprehensively, systematically and sequentially (children should be carried out according to routine pediatric procedures); for critically ill patients, it should be carried out according to the focus of the condition and flexibly. When a male doctor examines a female patient, a third party must be present.

General conditions: body temperature, pulse, respiration, blood pressure (record height and weight if necessary); development (normal, abnormal, poor); nutrition (good, moderate, poor, thin, obese); body position and posture (such as flexion position, inclined recumbent position, etc.); complexion (such as ruddy, dull, etc.); expression (anxiety, pain, chronic disease appearance); consciousness (clear, drowsy, semi-conscious, coma) and speech state (clear or not, Are they fluent, are their answers relevant to the topic?), are they cooperative during inspections, etc.

Skin color (normal, flushing, cyanosis, jaundice, paleness), elasticity, whether there is edema, sweating purpura, rash, pigmentation, vascular spiders, scars, wounds, ulcers, nodules. And Clearly describe its location, size and extent.

Whether lymph nodes are swollen in the whole body or local superficial lymph nodes, the size, number, location (submandibular, behind the ears, neck, supraclavicle, axilla, elbow, groin, etc.) should be noted. Hardness, tenderness and mobility; whether there is redness, heat, fistulas or scars on the local skin.

Head

Skull size, normal appearance or any abnormality; distribution of eyebrows; presence of boils, ringworm, trauma, scars, and masses.

Eyes: eye fissure size, eyelid and eye movement, cornea, conjunctiva, conjunctiva, sclera. Pupils (size, shape, symmetry on both sides, response to light, accommodation response), visual field and visual acuity (rough measurement). Fundus examination if necessary.

Ears: There are abnormalities in the auricle, whether there is secretion in the external auditory canal, whether there is tenderness in the ear beads and mastoids, and hearing (rough test).

Whether the nose is deformed, nasal flaring, obstruction, secretions, abnormal nasal septum and olfactory disorder, and whether there is tenderness in the sinuses.

Pigmentation; tongue coating, tongue texture, and whether there is deviation and tremor when extending the tongue; whether there are ulcers, pseudomembranes, and pigmentation on the oral mucosa; tonsil size, whether there is congestion, edema, and secretions; whether there is congestion or secretions in the pharynx , pharyngeal reflex, soft palate movement, whether the uvula is centered, and whether swallowing is normal.

Whether the neck is symmetrical, whether there is stiffness, tenderness, limited movement, venous distension, obvious arterial pulsation, and masses, and whether the trachea is centered. Whether there is enlargement of the thyroid gland. If it is enlarged, its shape, size, hardness, and whether there are nodules, tremors, tenderness, murmurs, etc. should be described.

Chest

Thoracic shape, symmetry, degree of movement, intercostal fullness or depression and other abnormalities, costal arch angle size, chest wall edema, subcutaneous emphysema, masses, and varicose veins . Check whether there are tenderness, depression and other abnormalities in the ribs and costal cartilage. * Condition (* position, * size, skin characteristics: whether there is redness, swelling, orange peel-like appearance, tenderness, lumps, etc.).

Inspection of the lungs: Breathing type, speed, depth, and whether the breathing movements on both sides are symmetrical.

Palpation: Whether the two sides of the voice tremor are equal and whether there is any friction.

Percussion: Percussion responses (voiceless, voiced, solid, tympanic sounds), the position of the lower boundary of the lungs and respiratory mobility.

Auscultation: pay attention to the nature of breath sounds (alveolar sounds, bronchoalveolar sounds, tubular breath sounds) and their intensity (reduced, enhanced, disappeared), speech conduction, and whether there are friction sounds, wheezes, and dry sounds. Sound, wet rales.

Heart Inspection: The location, range, and intensity of the apical pulse, and whether there are abnormal pulses and localized bulging in the precordium.

Palpation: at the apical pulsation site, whether there is a lifting impulse, whether there is tremor or friction (location, time, intensity).

Percussion: The left and right heart boundaries are recorded or drawn as the number of centimeters between the intercostal space and the midline of the sternum. The distance from the midclavicular line to the anterior midline must be noted.

Right cm Intercostal left cm

2.0 Ⅱ 3.0

3.0 Ⅲ 4.0

3.0 Ⅳ 6.0

Ⅴ 8.0

Auscultation: heart rate and rhythm. If the rhythm is irregular, the heart rate and pulse rate should be counted at the same time. The nature and intensity of the heart sounds in each valve sound area, whether there are heart sound splitting and the third and fourth heart sounds, and compare the intensity of the second sound of the aortic valve and pulmonic valve. Is there any noise?

Inspection of the abdomen: respiratory movement, whether the abdominal wall is symmetrical, whether there are depressions, bulges, varicose veins, peristaltic waves, localized bulges, and the condition of the umbilicus.

Palpation: The abdominal wall is soft or tense, whether there is tenderness, the location and extent of tenderness, whether you refuse to press or prefer to press, whether there is rebound tenderness; whether there is a lump, its location, size, shape, and hardness, Tenderness, range of motion, influence of respiratory movements, presence or absence of pulsations and fluctuations, etc.

Whether the liver is palpable. If palpable, the number of centimeters from the lower edge of the liver to the costal margin and xiphoid process at the midclavicular line should be recorded. Pay attention to the sharpness and hardness of the liver edge, and whether there is tenderness. When the liver is enlarged, pay attention to whether there is pulsation and whether there are nodules on the surface.

Whether the gallbladder is palpable, its size, and whether there is tenderness.

Whether the spleen can be palpated? If it can be palpated, it should be noted whether its surface is smooth, whether there are notches and tenderness, its hardness, and the distance in cm from the lower edge of the spleen to the thin edge of the midclavicular line (vertical diameter AB and oblique diameter AC) , the mobility of the spleen when lying on the back and side.

Whether the kidney can be palpated, size, mobility, whether there is tenderness, etc.

Percussion: the dullness boundary of the liver and spleen (the upper boundary is measured in intercostal space, the total length is measured in cm), and whether there is percussion pain in the liver and spleen areas. Whether there is excessive reverberation and shifting dullness in the abdomen.

Auscultation: Intestinal peristalsis sounds (normal, enhanced, weakened, disappeared) and their sound quality and frequency, whether there is vibrating water sound in the stomach area, and whether there is friction sound in the liver and spleen area. Whether there is vascular murmur, and record its location and nature.

The distribution of pubic hair on the vulva and anus; the development of the external genitalia, whether there is phimosis and urethral secretions; the location, size, and hardness of the testicles; whether there is tenderness, whether there are nodules, swelling and pain in the epididymis; whether there is enlargement of the spermatic cord Thickness, tenderness, nodules and varicose veins; whether the scrotum is desquamated, cracked and swollen. If there is swelling, use a transillumination test to determine whether there is fluid in the scrotum. Female genital examination (see gynecological examination) must be assisted by a female nurse or examined by a female physician. Anal examination should be performed to check whether there are external hemorrhoids, anal fissures, anal fistulas, anal prolapse, genital warts, etc. If necessary, a digital anorectal examination or anoscopy should be performed.

Whether there is deformity, tenderness, and percussion pain in the spine and limbs; whether there is tension and tenderness in the muscles on both sides of the spine; whether there is tenderness or percussion pain in the costovertebral angle; whether there is deformity, clubbing of the fingers and toes in the limbs , edema, varicose veins, trauma, fractures; muscle tension and strength, whether there is atrophy; whether joints are red, swollen, deformed and have movement disorders; whether there is microvascular pulsation in the nail bed; whether there is gunshot sound in the femoral artery and brachial artery; whether there is radial artery pulsation and blood vessel wall stiffness.

Nervous system: movement and sensation of limbs, knee tendon reflex, Achilles tendon reflex, biceps tendon reflex, triceps tendon reflex, abdominal wall reflex, cremasteric reflex, Babinski sign, K?nig sign wait.

Specialty status: For example, surgical medical records must include surgical status, and other departments such as ophthalmology, gynecology, etc. should describe the relevant signs of the specialty in a focused, detailed, true and systematic manner. See the medical record writing requirements for each specialty.

Tests and other tests The main tests that should be completed within 24 hours after admission, such as routine tests of blood, urine, and feces, as well as X-rays, electrocardiograms, etc. Important test results before admission can be recorded in the medical history.

Summary: Use about 100 to 300 A to briefly and concisely summarize the key points of medical history, positive test results, important negative results and related test results.

Preliminary diagnosis: Those whose main injuries have been diagnosed when admitted to hospital can write: "diagnosis". Based on the complete medical history and preliminary examination results, through comprehensive analysis, a preliminary diagnosis of all existing diseases can be made and listed in separate lines. The order is based on the following principles: major diseases first, minor diseases last; primary diseases first, other diseases last. If there is more than one possible main diagnosis, select 1 or 2 of the possibilities and write them down. In the diagnosis name, write the disease name first, and then record the type, location, and side as needed; if the diagnosis name is more complex, it can be listed in separate lines according to etiological diagnosis, pathological diagnosis, anatomical diagnosis, pathophysiological diagnosis, and functional diagnosis. The preliminary diagnosis is recorded on the right side of the medical record.

When writing medical records that combine traditional Chinese and Western medicine, Western medicine diagnosis is juxtaposed with Chinese medicine diagnosis.

Signature: The above-mentioned admission medical record shall be recorded and signed by the intern and newly arrived physician, and then reviewed by the resident physician, who shall correct it with a red pen and sign the full name on the left side, separated by a slash. . Handwriting must be straight and clear.

Final diagnosis: After the main disease is diagnosed, write down the final diagnosis in a timely manner (record it on the left half of the medical record paper at the same height as the initial diagnosis), including the name of the disease, date of diagnosis, and signature. When the final diagnosis is exactly the same as the preliminary diagnosis, you can write: "Same as right" under the final diagnosis item. The final diagnosis is recorded by the resident physician and signed by the attending physician after review.

2. Admission record

The content and order of the admission record are generally the same as the admission medical record, but the general items and chief complaint can be written in one paragraph. Past history, personal history, family history, etc. Negative information unrelated to the disease in items such as history and physical examination can be streamlined appropriately and reduce paragraphs. The subtitles of name, age, current medical history, past history, family history and physical examination items can be omitted as appropriate. Don’t write a summary. The admission record is recorded and signed by the resident physician. It is reviewed and revised by the attending physician and signed on the left side of the resident physician's name. If the intern writes the admission record with the consent of the attending physician, it will be reviewed, corrected and signed by the resident physician. The final diagnosis on the admission record is recorded and signed by the attending physician.

3. Diagnosis discussion and diagnosis and treatment plan

Resident physicians or interns should write a diagnosis discussion and plan diagnosis and treatment as needed (for example, if the diagnosis is difficult to make clear or the condition is serious or the treatment is complicated) Plan, but it must be focused and concise. It should include:

(1) Analysis and discussion: Purposely summarize, analyze and discuss the main symptoms, time, and evolution, physical examination findings and auxiliary examination results, and briefly and concisely put forward the reasons for the proposed diagnosis and the main reasons. Differential diagnosis. Forget about rigidly repeating the basic elements of the admission record.

(2) Preliminary diagnosis includes major and minor diseases, confirmed and unconfirmed (same as admission record).

(3) Diagnosis and treatment plan: Based on the preliminary diagnosis, the examination items, completion date and treatment plan are formulated. The attending physician must personally review the plan and supervise its implementation.

If the content of the diagnosis discussion and treatment plan is relatively simple, it can also be included in the first record of the disease course record. If the content is more complex, it should be included in one paragraph.

IV. Record of disease course

(1) Recording time The changes in condition and diagnosis and treatment status after admission shall be recorded in time by the resident physician or intern physician in chronological order. Critical and changeable conditions should be recorded at any time; those with severe illness should be recorded at least once a day; those with more stable conditions may be briefly recorded if necessary, but at least once a week.

(2) Content

1. The first recording of the disease course after admission should be completed on the same day. It mainly writes about the patient's condition on the day after admission, the diagnostic and treatment measures that have been taken, the preparations for diagnosis and treatment that have been carried out, the patient's difficulties, how to help solve them, etc. If the diagnostic discussion and treatment plan are not listed in a separate section, they can be described in this section.

2. The patient’s current chief complaint, changes in condition, mood, diet, sleep, etc., important findings of physical examination and examination, progress of diagnosis and treatment, and analysis of the condition must be insightful.

3. Special inspection results and judgment.

4. All diagnosis and treatment operation records should include the surgical steps, main findings of the operation and the patient's condition after the operation. For the surgical records and postoperative course of the surgical department, please refer to the relevant items.

5. The opinions of the chief physician, attending physician and other superior physicians during their rounds or consultations should be recorded in detail and accurately.

6. The judgment, handling and consequences of special changes should be recorded immediately.

7. Important opinions from administrative leaders, important matters explained by patients’ families and organizational leaders.

8. Summary after each stage of examination or treatment, future diagnosis and treatment opinions, and handover records.

9. If it is a record of the disease course of integrated traditional Chinese and Western medicine, the dialectical treatment of traditional Chinese medicine should be recorded, such as changes in syndrome types, changes in prescriptions, observation and analysis of traditional Chinese medicine, etc. Traditional Chinese medicine or acupuncture prescriptions should be recorded in the traditional Chinese medicine prescription record sheet or disease course record.

10. Reasons should be given for any modification of the original diagnosis and determination of a new diagnosis.

11. All diagnosis and treatment work performed by doctors on duty or on duty during their duty or substitute hours should be recorded in the disease course record according to the needs of the condition.

12. When the patient is discharged, a discharge record or discharge summary should be written in the inpatient medical record and outpatient medical record. The content should include the time of admission, the situation at that time, the evolution of the condition, the diagnosis and treatment process and lessons learned, the situation at the time of discharge, Length of hospitalization, final diagnosis and instructions.

Attached are general routine tasks during the course of the disease

The following routine tasks are completed by interns or residents; if completed by interns, the residents are responsible for review.

(1) Disease course records should be written according to the aforementioned disease course record requirements.

(2) High blood pressure: For those with normal blood pressure upon admission, the blood pressure will be measured once a day for 2 consecutive days; for those with elevated or low blood pressure, the number of measurements will be increased as appropriate.

(3) Blood routine In addition to routine examinations upon admission, the items, time and frequency of review should be determined according to the needs of the patient's condition. For example, patients with acute fever should be checked every 1 to 3 days; those with long-term fever should be checked at least once a week; patients who use drugs or radiation therapy that affect the blood system should be checked at least twice a week.

(4) Routine urine examination at least once. Patients with fever or those who may develop kidney damage during treatment should take at least 2 times a week.

(5) Routine fecal examination at least once. If any problems are found, review them as necessary.

(6) Inspection records Routine inspection results of blood, urine and feces should be copied to the inspection record sheet (including date, inspection results, and examiner) in a timely manner. Or, like other inspection reports, neatly affix them to the left side of the special paper from top to bottom in order of report date. A blue and black pen can be used on the upper edge of each inspection report (red pen can be used for important positive results) to briefly record the inspection date for easy reference. . If a new report form is used with the inspection date and results recorded on the top, the annotation can be omitted.

5. Transfer records

(1) Transfer to another department Those who need treatment from another department due to their illness can only be transferred after consultation with the consent of the physician in charge of the other department and the attending physician of the department. Department; in emergency situations, residents can also directly contact the transfer department.

(2) Transfer-out record Before transferring to another department, the resident physician or intern should write the transfer-out record, which includes:

1. General items such as name, gender, age, etc.

2. Current medical history, medical history related to the department to which you are transferred, and important past medical history.

3. Important findings from physical examinations, examinations and other examinations;

4. Treatments performed by the undergraduate and their effects.

5. The evolution of the condition, undergraduate opinions and consultation opinions;

6. Diagnosis or preliminary diagnosis.

(3) Transferred records: The content of the admission record includes a brief description of the diagnosis and treatment process after admission. Since it must focus on undergraduate diseases, the content of the record may be different from the original admission medical record.

6. Discharge record

It is written by the resident physician or intern before the patient is discharged. The content is basically similar to the medical record summary: the situation on admission and various examination results, the diagnosis and treatment status and condition after admission. Improvement, remission, degree of recovery, discharge date and length of hospitalization; discharge diagnosis, discharge instructions.

7. Death record

If a patient dies due to ineffective treatment during hospitalization, a death record should be written immediately, including: medical record summary, evolution of the condition during hospitalization, rescue process, and time of death. , cause of death, lessons learned, and final diagnosis.

8. Readmission medical records

When a patient is hospitalized again, it should be noted on the medical record how many times the patient has been hospitalized. Note that the writing content is different in the following two situations:

1. If you are hospitalized again due to the recurrence of an old disease, you must record the summary of past medical records and the condition and treatment process from the last discharge to the current admission in the medical record in detail. The past history, personal history, and family history can be obtained from slightly.

2. Re-hospitalization due to a new disease must be written in a complete hospitalization medical record format, and past hospitalization diagnoses must be included in the past history.

9. Special records

In order to facilitate the summary of clinical experience, improve the quality of medical care, and conduct teaching and scientific research, some special records can be drawn up for some common injuries and special treatment processes. Form and fill it out as required. Special record forms are not intended to replace formal medical records and documentation.

10. Medical record abstract

(1) Filling in procedures If a medical record abstract is required for transfer, discharge, or out-of-hospital consultation, it must be written by a resident physician or intern. After being reviewed and signed by the attending physician or chief physician, it will be sent to the Medical Office for review and official seal. Depending on the specific circumstances, it will be decided whether the patient or escort will take it or mail it.

(2) Content 1. General items, recorded according to the admission record items; 2. Admission conditions and various examination results; 3. The course of the disease, treatment status and degree of cure; 4. Final diagnosis; 5. The current condition of the patient; 6. Fill in future treatment, treatment and other precautions if necessary. When inviting out-of-hospital consultation, the purpose of the consultation should be stated.