1. Content of medical record writing: Medical record writing should be objective, true, accurate, timely and complete. Ensure the objectivity and truthfulness of medical records, and it is strictly forbidden for medical institutions to alter or forge medical records. If a medical institution alters or forges a medical record, the altered or forged part is invalid, and it shall be handled in favor of the patient. The content of the medical record is complete, that is to say, the medical record must contain the specified items. In addition to the incompleteness caused by patients, medical institutions will bear adverse consequences for incomplete medical records. Medical records consist of outpatient (emergency) medical records and inpatient medical records. The contents of outpatient (emergency) medical records include the first page of outpatient medical records (the cover of outpatient manual), medical records, laboratory sheets (inspection reports), medical imaging examination data, etc. The first page of 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. 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. When patients see a doctor, the attending physician should fill in the outpatient (emergency) consultation medical records in time. When rescuing critically ill patients, rescue records should be written. For patients admitted to the emergency observation room, the observation records of the observation period shall be written. The contents of in-patient medical records include the first page of in-patient medical records, hospitalization records, temperature sheets, doctor's orders, laboratory examinations (inspection reports), medical image examination data, special examination (treatment) consent, operation consent, anesthesia records, operation and surgical nursing records, pathological data, nursing records, discharge records (or death records), course records (including rescue records), discussion records of difficult cases and consultation opinions. All the above contents have their own constituent elements and recording requirements. You must write as required, or you will be at your own risk.
2. Writing form of medical records: blue-black ink and carbon ink should be used to write hospital medical records, and blue or black oil-water ballpoint pen can be used to copy outpatient (emergency) medical records and materials. In violation of these regulations, which affects the fact investigation, medical institutions shall bear the adverse consequences. Medical record writing should be neat, clear, accurate, fluent and punctuated correctly. When typos appear in the writing process, they should be drawn with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting. In violation of regulations, we think that the rewritten part is invalid when it is covered up or removed, except for the benefit of patients; Re-writing the hidden or removed place should be carried out according to the specific content of the medical record and the principle of benefiting the patient. If the medical records cannot be written in time due to the rescue of critically ill patients, the relevant medical personnel shall make up the facts within 6 hours after the rescue and make records. In violation of the provisions, there is evidence to prove that the record is overdue, which shall be regarded as unrecorded and handled in favor of the patient. Medical institutions must abide by the above provisions when writing medical records, otherwise they will bear adverse consequences.