Arrangement of medical records for in-patient observation
(1) Organize medical records during the observation period.
Temperature list
List of medical advice
Emergency hospitalization observation record
Course records (in page number order)
Laboratory test report
Inspection list
⑵ Arrange medical records after discharge.
Emergency hospitalization observation record
Course records (in page number order)
Inspection list
Laboratory test report
List of medical advice
Temperature list
2. Ordering of inpatient medical records
(1) medical records during hospitalization
Temperature list (reverse by date)
Temporary medical orders (in reverse order of date)
Long-term doctor's orders (in reverse order of date)
Special treatment record sheet (such as hormone therapy, insulin therapy, chemotherapy, radiotherapy, etc.). )
Admission records (including readmission records, admission and discharge records within 24 hours, admission and death records within 24 hours)
Course record (in chronological order)
Discussion record of difficult and critical cases
Consultation record form
All kinds of informed medical documents
Preoperative discussion record
Surgical plan
Operational safety verification record
Operation record or delivery record
Anesthesia record
Various examination reports: X-ray report, angiography, CT, MRI and other radiological examinations, ultrasonic examination, electrocardiogram examination report, pathological report and other special examination reports (in order of date).
Test report: Stick it on the special adhesive sheet from bottom to top, and mark the test items and date with red ink pen at the bottom of the test sheet for easy searching. (sorted by date)
A. Three general report pasting pages
B. Sticking pages of biochemical and immunological reports
C. Paste page of instrument inspection report
D. Paste page of blood type, blood matching list and blood transfusion record
E. Paste page of expert report
Nursing records (general patient nursing records, critically ill patient nursing records and operation counting records) are classified in reverse order by date.
Admission certificate
Medical record home page
Hospital medical record quality evaluation scale
Outpatient medical records
(2) enter the medical record room to sort out medical records.
Medical record home page
Admission records (including readmission records, admission and discharge records within 24 hours, admission and death records within 24 hours)
Course record (in chronological order)
Discharge record or death record
Discussion record, preoperative discussion and surgical plan of difficult and critical cases
Discussion record of death cases
Consultation record form
All kinds of informed medical documents
Operational safety verification record
Operation record or delivery record
Anesthesia record
All examination reports: X-ray report, angiography, CT, MRI and other radiological examinations, ultrasonic examination, electrocardiogram examination report, pathological report and other special examination reports (in order of date).
Test report: Stick it on special adhesive paper from bottom to top, and mark the test items and date with red ink pen at the bottom of the test sheet for easy searching. (In chronological order of categories)
Temperature list (in alphabetical order)
Temporary doctor's orders (by page number)
Standing orders (in alphabetical order)
Special treatment record sheet (such as hormone therapy, insulin therapy, chemotherapy, radiotherapy, etc.). )
Nursing records (ordinary patient nursing records, critically ill patient nursing records, operation counting records)
Admission certificate
Final medical record quality evaluation scale