Admission is the initial diagnosis, followed by admission diagnosis, followed by correction diagnosis. If the first diagnosis is consistent with the admission diagnosis, that is, the first diagnosis has the signature of the attending physician or above, that is, the first diagnosis is automatically recognized as the admission diagnosis. If the diagnosis is added or modified, the modified diagnosis should be written on the lower left of the admission diagnosis and signed by the superior doctor.

The main symptoms or signs and the onset period of the patient. This term is expressed in Arabic numerals. Symptoms or signs come first, and the onset time is late. Chief complaint can guide doctors to diagnose diseases. If the interval of hemoptysis is 1 year, it means that it is a lung or bronchial disease. The time of chief complaint is consistent with the time of current medical history, and the first diagnosis should be consistent with the chief complaint.

Special patients can take diagnostic physical examination as the main complaint. For example, patients with esophageal cancer come to the hospital for chemotherapy after 6 months, which can be written as 6 months after esophageal cancer surgery, the second hospitalization chemotherapy and so on. It is related to cancer and surgical site, time and treatment needs.

Expand the records of patients' treatment outcome and condition changes, and focus on determining patients' shock, heart failure, hemoptysis, fever, abdominal pain, vomiting, operation time, treatment process and outcome. The first medical record should be written by the doctor on duty, which can reflect the doctor's thinking. The medical record should reflect the second-level ward round, the third-level ward round and the discussion of difficult diseases. The rescue of critically ill patients must be attended by superior doctors, not just one person.

Even if the doctor is the attending doctor, it can't be like this, which is conducive to preventing medical disputes. Changes of important drugs, such as antibiotics, cardiotonic agents, antihypertensive drugs, antihypertensive drugs, etc. All kinds of auxiliary examination results should be recorded in the medical record of the day, and special records should be written for abdominal puncture, lumbar puncture, catheterization and chest puncture. Surgical patients should reflect the indications and operation time, and fighting for time is life. Preoperative discussion and surgical records should be written according to the requirements of the Health Planning Commission. Attention should be paid to the opinions of the consultants, and the consultation sheet should have specific consultation time. Pay attention to the surgeon and write the operation record. Please ask the professor outside the hospital to write relevant medical documents in person, such as writing surgical records and consultation sheets.