Chapter I General Provisions
Section 1 Basic Concepts
Section 2 Principles and Basic Requirements of Medical Record Writing
In the third quarter, the new specification changes
Chapter II Common Medical Documents
Section 1 Specification and Requirements for Writing the First Page of Hospitalized Medical Records
In the second quarter, the people's hospital medical record writing format and requirements
Section 3 Standards and Requirements for Writing Medical Records in People's Hospitals
The fourth quarter course record writing norms and requirements
Section 5 consent form for operation
Section 6 Anesthesia Consent
Section 7 informed consent of blood transfusion treatment
Section 8 Consent for Special Examination and Special Treatment
Section 9 critically ill (heavy) notice
Section 10 medical advice
Section 11 Auxiliary Inspection Report
Section 12 discharge record
Chapter III Examples of Common Medical Documents
The fourth chapter outpatient (emergency) medical record writing requirements and examples.
Section 1 Contents, styles and writing requirements of first-visit (follow-up) medical records on the first page of medical records (cover of manuals).
The second section initial (re-diagnosis) writing content and examples
Section 3 Requirements and Examples of Emergency Medical Records Writing
The fourth quarter emergency observation record writing requirements and examples
Chapter V Characteristics and Examples of Medical Records Writing in Various Departments
The first section Gastroenterology medical records writing requirements and examples
Section 2 Requirements and Examples of Medical Records Writing in Endocrinology Department
Section 3 Requirements and Examples of Medical Records Writing in Respiratory Medicine
The fourth quarter neurology medical record writing requirements and examples
Section 5 Requirements and Examples of Medical Records Writing in Nephrology Department
Section 6 Requirements and Examples for Writing Rheumatology Medical Records
Section 7 Requirements and Examples of Medical Records Writing in Cardiology Department
Section 8 Requirements and Examples of Medical Records Writing in Hematology Department
Section 9 Requirements and Examples of Writing Psychiatric Medical Records
Section 10 Requirements and Examples of Medical Records Writing in Infectious Diseases Department
Section 1 1 Requirements and Examples of Medical Records Writing in Tuberculosis Department
Section 12 Requirements and Examples of Medical Records Writing in Oncology Department
Section 13 Requirements and Examples of Medical Records Writing in Geriatrics Department
Section 14 Requirements and Examples of Dermatology Medical Record Writing
Section 15 Pediatric Medical Records Writing Requirements and Examples
Section 16 Requirements and Examples for Writing General Surgical Medical Records
Section 17 Requirements and Examples of Medical Records Writing in Thoracic Surgery
Section 18 Requirements and Examples of Urology Medical Records Writing
Section 19 Requirements and Examples of Orthopedic Medical Records Writing
Section 20 Requirements and examples of neurosurgery medical record writing
Section 21 Requirements and Examples of Medical Records Writing in Cardiovascular Surgery
Section 22 Requirements and Examples for Writing Medical Records of Hepatobiliary Surgery
Section 23 Requirements and Examples for Writing Medical Records of Burn Surgery
Section 24 Writing Requirements and Examples of Anorectal Surgery Medical Records
Section 25 Requirements and Examples of Medical Records Writing in Kidney Transplantation Department
Section 26 Requirements and Examples of Medical Records Writing in Minimally Invasive Surgery
Section 27 Requirements and Examples of Plastic Surgery Medical Records Writing
Section 28 Requirements and Examples for Writing Medical Records of Cosmetic Surgery
Section 29 Requirements and Examples of Gynecological Medical Records Writing
Section 30 Requirements and Examples of Obstetric Medical Records Writing
Section 3 1 Requirements and examples for writing ophthalmic medical records
Section 32 Requirements and Examples of Otolaryngology Medical Records Writing
Section 33 Requirements and Examples for Writing Medical Records of Oral and Maxillofacial Surgery
Section 34 Requirements and Examples for Writing Hyperbaric Oxygen Medical Records
Chapter VI Contents and Order of Medical Records
The first section running medical records arrangement order
In the second quarter, the order of discharge medical records
Nursing part
Chapter VII General Provisions
Section 1 Basic Concepts
Section 2 Basic Requirements for Writing Nursing Documents
Chapter VIII Basic Requirements for Writing Various Record Sheets
The first section temperature list
In the second quarter, the doctor's advice list
In the third quarter critically ill (heavy) patients nursing record sheet
The fourth quarter operation inventory record
Appendix I Evaluation Criteria for Writing Quality of Outpatient Medical Records in Medical Institutions (Trial)
Appendix II Basic Specification for Medical Record Writing issued by the Ministry of Health (full text)
Appendix III Basic Specification for Electronic Medical Records (Trial)
Appendix IV Basic Nursing Services for Inpatients (Trial)
Appendix V Basic Nursing Service Work Specification
Appendix VI Common Clinical Nursing Technical Service Specifications