Regulatory documents for medical record writing
Notice of the Ministry of Health on the issuance of the "Basic Standards for Writing Medical Records"
The Ministry of Health on the issuance of the "Basic Standards for Electronic Medical Records (Trial)" 》Notice
Notice of the Ministry of Health on the issuance of the "Prescription Management Measures"
Notice of the Ministry of Health on the issuance of the "Hospital Prescription Review Management Standards (Trial)"
Excerpts from medical-related chapters of the Tort Liability Law of the People's Republic of China
Hunan Province Medical Record Writing Standards
Overview of Chapter 1
Section 1 Standardizing medical records
1. Classification and name definitions of medical records
2. The status and role of medical records
Section 2. Basic regulations for writing medical records
< p>1. Format2. Time limit
3. Writing requirements
Chapter 2 Medical Record Writing Standards
Section 1 Medical Records Types and formats of writing
Outpatient medical records
Emergency (observation) medical records
Inpatient medical records
Home page of inpatient medical records
Complete hospitalization medical records
Admission records
Re- or multiple admission records
Discharge records within 24 hours
24 Record of death within hours of admission
Record of disease course
Record of first disease course
Record of daily disease course
Record of ward rounds by superior physician
Difficult case discussion records
Shift handover records
Shift handover records
Shift succession records
Transfer and admission records
Transfer (transfer out) record
Receipt (transfer in) record
Stage summary
Rescue record
< p>Invasive diagnosis and treatment operation recordsInterventional treatment records
Consultation records
......
Chapter 3 Hospitalization Cases (Case) Medical Quality Assessment Standards
Chapter 4 Medical Record Management
Appendix