1, the medical record writing should be objective, true, accurate, timely, complete and standardized.

2, medical records should be written in blue and black ink, carbon ink, medical records to be copied can use blue or black oil-water ballpoint pen. Computer printed medical records shall meet the requirements of medical record preservation.

3, medical records should be written in Chinese, commonly used foreign abbreviations and symptoms, signs, disease names without formal Chinese translation can be used in foreign languages.

4. Medical records should be written in standardized medical terms, with neat handwriting, clear handwriting, accurate expression, fluent sentences and correct punctuation.

5. When typos appear in the process of medical record writing, they should be marked with double lines, and the original records should be kept clear and easy to read, with the revision time indicated and signed by the reviser. Scraping, gluing, painting and other methods shall not be used to cover up or remove the original handwriting.

Medical record writing includes content.

Case writing generally refers to the writing of hospitalized cases, including general situation, present medical history of chief complaint, past history, personal history, physical examination, auxiliary examination and diagnosis.

1, generally including the patient's name, gender, race, age, address, etc.

2. The chief complaint is the current medical history. It is necessary to describe the main reason for the patient's hospitalization as the chief complaint, refine the cause, time, course and current situation of the illness, and introduce the admission method.

3. Past medical history needs to describe whether the patient has chronic diseases, infectious diseases, surgery, drugs, allergies and blood transfusion.

4. Personal medical history needs to describe the patient's vaccination, travel, smoking and drinking.

5. Family history needs to describe whether there are family clustering diseases or genetic diseases in the patient's family; For example, women also need to describe menstruation.

6. Systematic physical examination includes eight simple systems of human body, such as circulatory system, respiratory system and digestive system.

7. The specialist physical examination requires a targeted and professional further physical examination of the symptoms of this hospitalization.

8. The auxiliary examination needs to record whether the patient has completed the relevant examination of this hospitalized disease and what is the result.