Chapter I Basic Requirements

Article 1 Medical records refer to the sum of words, symbols, charts, images, slices and other materials formed by medical personnel in the process of medical activities, including outpatient (emergency) medical records and inpatient medical records.

Article 2 Medical record writing refers to the behavior of medical staff to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment and nursing, and to summarize, analyze and sort out the records of medical activities.

Article 3 The writing of medical records shall be objective, true, accurate, timely and complete.

Article 4 The inpatient medical records shall be written in blue-black ink and carbon ink, and the outpatient (emergency) medical records and photocopied materials may be written in blue or black oil-water ballpoint pen.

Article 5 Medical records shall be written in Chinese and medical terms. Commonly used foreign language abbreviations and names of symptoms, signs and diseases without official Chinese translation can be used in foreign languages.

Article 6 The writing of medical records shall be neat, clear, accurate, fluent and punctuated. When typos appear in the writing process, they should be marked with double lines, and the original handwriting should not be covered or removed by scraping, gluing or painting.

Seventh medical records should be written in accordance with the provisions, and signed by the corresponding medical personnel. Medical records written by interns and trainee medical personnel shall be reviewed, revised and signed by medical personnel who are legally practicing in this medical institution. Medical personnel receiving continuing education should write medical records after being approved by medical institutions receiving continuing education according to their actual qualifications for professional work.

Eighth superior medical personnel have the responsibility to review and modify the medical records written by lower medical personnel. When modifying, the date of modification shall be indicated, and the signature of the modifier shall be clear and readable.

Ninth because of the rescue of critically ill patients can not write medical records in time, the relevant medical personnel shall truthfully fill in the record within 6 hours after the rescue, and make records.

Tenth medical activities (such as special examination, special treatment, surgery, experimental clinical treatment, etc.). If the patient's written consent is required in accordance with relevant regulations, it shall be signed by the patient himself. When the patient does not have full capacity for civil conduct, it shall be signed by his legal representative; If the patient is unable to sign due to illness, it shall be signed by his close relatives; if there are no close relatives, it shall be signed by his related person; In order to rescue patients, if the legal representative or close relatives or related parties cannot sign in time, the person in charge of the medical institution or the authorized person in charge may sign.

If it is not appropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's close relatives shall be informed of the relevant situation, and the close relatives of the patient shall sign the consent form and record it in time. If the patient has no close relatives or the patient's close relatives are unable to sign the consent form, the consent form shall be signed by the patient's legal representative or relevant person.

Chapter II Requirements and Contents of Outpatient (Emergency) Medical Records

Eleventh 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.

Twelfth 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, drugs, etc.

Allergy history and other items.

Thirteenth 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, subjects, chief complaint, current medical history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions and doctor's signature.

Name, 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.

Fourteenth outpatient (emergency) medical records should be filled in by the attending physician in time when the patient is hospitalized.

Fifteenth 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.

Chapter III Requirements and Contents of Inpatient Medical Records Writing

Article 16 The contents of in-patient medical records include the first page of in-patient medical records, hospitalization records, temperature sheets, doctor's orders, laboratory sheets (examination reports), medical image examination data, special examination (treatment) consent, operation consent, anesthesia records, surgery and surgical nursing records, pathological data, nursing records, discharge records (or death records), course records (including rescue records), discussion records of difficult cases and medical records.

Seventeenth hospital medical records refer to the records obtained by the attending doctor through consultation, physical examination and auxiliary examination after the patient is admitted to the hospital, and these materials are summarized, analyzed and written. The writing forms of hospitalization records are divided into admission records, readmission records, admission and discharge records within 24 hours, admission and death records within 24 hours. Admission records and readmission records should be completed within 24 hours after the patient is admitted to the hospital;

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The admission and discharge records within hours should be completed within 24 hours after the patient leaves the hospital, and the admission and death records within 24 hours should be completed within 24 hours after the patient dies.

Article 18 Requirements and contents of admission records.

(1) The general information of patients includes name, gender, age, nationality, marital status, birthplace, occupation, date of admission, date of record and medical history statement.

(2) Chief complaint refers to the main symptoms (or signs) of patients and the duration of treatment.

(three) the current medical history refers to the details of the occurrence, evolution, diagnosis and treatment of the patient's disease, which should be written in chronological order. The contents include the incidence, the characteristics and development of main symptoms, accompanying symptoms, the course of disease and the results of diagnosis and treatment after onset, changes in general conditions such as sleep and diet, and positive or negative data related to differential diagnosis. Other diseases that are not closely related to this disease but still need treatment can be recorded in another paragraph after the current medical history.

(4) Past history refers to the patient's past health and illness. The contents include general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, drug allergy history, etc.

(5) Personal history, marriage and childbearing history, menstrual history of female patients and family history.

(6) Physical examination writing should be systematic and orderly. The contents include temperature, pulse, respiration, blood pressure, general condition, skin, mucosa, superficial lymph nodes, head and its organs, neck, chest (chest, lung, heart, blood vessels), abdomen (liver, spleen, etc. ), rectum and anus, external genitalia, spine, limbs, nervous system, etc.

(seven) the special circumstances of the profession should be recorded according to the needs of the profession.

(eight) auxiliary examination refers to the main examination and its results related to this disease before admission. The date of inspection shall be stated, and the name of the institution shall be stated if the inspection is carried out in other medical institutions.

(9) Preliminary diagnosis refers to the diagnosis made by the attending physician according to the comprehensive analysis of the patient when he is admitted to the hospital. If the initial diagnosis is multiple, the priority should be clear.

(ten) the signature of the doctor who wrote the admission record.

Nineteenth readmission or multiple admission records refer to the records written by patients who were hospitalized in the same medical institution for the same disease or multiple hospitalizations. The requirements and contents are basically the same as the admission record, and its characteristics are as follows: the chief complaint records the main symptoms (or signs) and duration of the patient's admission; In the current medical history, it is required to summarize the previous hospitalization experience before this hospitalization, and then write the current medical history of this hospitalization.

Twentieth patients who are discharged less than 24 hours after admission can write the admission and discharge records within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, discharge time, chief complaint, admission, admission diagnosis, diagnosis and treatment process, discharge, discharge diagnosis, discharge doctor's order, doctor's signature, etc.

Twenty-first patients who died less than 24 hours after admission can write death records within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, death time, chief complaint, admission situation, admission diagnosis, diagnosis and treatment process (rescue process), cause of death, death diagnosis, doctor's signature, etc.

Twenty-second course record refers to the continuous record of the patient's condition and diagnosis and treatment process after hospitalization record. The contents include patient's condition change, important auxiliary examination results and clinical significance, superior doctors' rounds, consultation opinions, doctors' analysis and discussion opinions, diagnosis and treatment measures and effects, changes and reasons of doctor's orders, important matters to inform patients and their close relatives, etc.

Article 23 Requirements and contents of course records.

(a) the first course record refers to the first course record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first visit record include case characteristics, diagnosis basis, differential diagnosis and treatment plan.

(two) the daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by doctors, but also by interns or trainee medical staff. When writing the daily course record, mark the date of the record first, and record the specific content in another line. For critically ill patients, the course of the disease should be recorded at any time according to the change of the condition, at least/kloc-0 times a day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days. For patients with chronic diseases whose condition is stable, the course of disease should be recorded at least once every 5 days.

(3) The records of superior doctors' rounds refer to the records of patients' condition, diagnosis, differential diagnosis, curative effect analysis of current treatment measures and opinions on the next diagnosis and treatment.

The attending physician's first round of rounds should be completed within 48 hours after the patient is admitted to the hospital. The contents include name, professional and technical position, supplementary medical history and signs, diagnosis basis, differential diagnosis and treatment plan, etc. The time interval of the attending physician's daily rounds is determined according to the condition and diagnosis and treatment, including the name of the attending physician, professional and technical positions, condition analysis and diagnosis and treatment opinions. The records of ward rounds of doctors with professional and technical positions or above, including the names of ward rounds doctors, professional and technical positions, illness analysis, diagnosis and treatment opinions, etc.

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(4) The discussion record of difficult cases refers to the record presided over by the director of the department or a physician with professional and technical qualifications above the deputy chief physician, and convened relevant medical personnel to discuss cases with difficult diagnosis or uncertain curative effect. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.

(5) The shift (pick-up) record refers to the record that the shift doctor and the succession doctor briefly summarize the patient's condition and diagnosis and treatment respectively when the patient's attending doctor changes. The log record shall be filled in by the log doctor before the log; The doctor of succession should make a record of succession within 24 hours after succession.

Finish it in. The contents of the handover record include admission date, handover or handover, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in handover or handover diagnosis and treatment scheme, and doctor's signature.

(6) The record of changing majors refers to the records written by the doctors in the transfer-out department and the transfer-in department respectively after the patient needs to change majors during hospitalization and agrees to receive them. Include a transfer-out record and a transfer-in record. The transfer-out record is written by the doctor in the transfer-out department before the patient is transferred out of the department (except for emergency); The transfer-in record should be completed by the doctor in the transfer-in department within 24 hours after the patient is transferred. The contents of the transfer record include admission date, transfer-out or transfer-in date, patient's name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in transfer-out or transfer-to-treatment scheme, and doctor's signature.

(seven) stage summary refers to the patient's hospitalization time is longer, and the monthly summary of the condition and diagnosis and treatment made by the attending physician. The contents of the stage summary include admission date, summary date, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, doctor's signature, etc.

Changes in handover (pick-up) records and main records can replace stage summary.

(eight) the rescue record refers to the record made when the patient is in critical condition and takes rescue measures. The contents include the change of illness, the time and measures of rescue, the names of medical personnel who participated in the rescue and their professional and technical positions. Record the rescue time to the minute.

(nine) consultation records (including consultation opinions) refers to the records written by the applicant and the consultant respectively when the patient needs the assistance of other departments or other medical institutions during hospitalization. The contents include application for consultation records and consultation opinions records. The record of application for consultation shall briefly explain the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and shall be signed by the consultant. Consultation record

There should be consultation opinions, the name of the department or medical institution where the consultant works, the consultation time and the signature of the consultant.

(10) Preoperative summary refers to the summary of the patient's condition made by the attending physician before operation. The contents include brief illness, preoperative diagnosis, surgical indications, the name and method of the operation to be performed, the anesthesia method to be performed, and matters needing attention.

(1 1) Preoperative discussion record refers to the discussion on the operation mode to be adopted, possible problems and countermeasures during the operation under the auspices of a superior doctor before the operation because the patient is seriously ill or the operation is difficult. The contents include preoperative preparation, surgical indications, surgical plan, possible accidents and preventive measures, names of participants, professional and technical positions, discussion date, signature of recorder, etc.

(12) Anesthesia record refers to the record of anesthesia process and treatment measures written by anesthesiologists during anesthesia implementation. Anesthesia records should be written on a separate page, including the general situation of patients, medication before anesthesia, preoperative diagnosis, intraoperative diagnosis, anesthesia mode, medication and treatment during anesthesia, starting and ending time of operation, signature of anesthesiologist, etc.

(thirteen) the operation record refers to the special record written by the operator to reflect the general situation of the operation, the operation process, the findings and handling during the operation, and shall be completed within 24 hours after the operation. Under special circumstances, when written by the first assistant, it should be signed by the operator. The operation record should be written on a separate page, including general items (patient's name, gender, department, ward, bed number, inpatient medical record number or medical record number), operation date, preoperative diagnosis, intraoperative diagnosis, operation name, operator's and assistant's name, anesthesia method, operation process, intraoperative situation and treatment, etc.

(14) surgical nursing records refer to the records made by visiting nurses on the nursing situation of surgical patients and the instruments and dressings used, which should be completed immediately after the operation. Surgical nursing records should be written on a separate page, including the patient's name, hospital medical record number (or medical record number), operation date, operation name, intraoperative nursing, and counting and checking the number of various instruments and dressings used. Signature of visiting nurse and surgical instrument nurse.

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(15) The first course record after operation refers to the course record completed by the doctors involved in the operation immediately after the operation. The contents include operation time, intraoperative diagnosis, anesthesia mode, operation mode, brief operation flow, postoperative treatment measures and matters needing special attention after operation.

Twenty-fourth surgical consent refers to the medical document that the patient is informed by the attending physician before the operation and the patient signs the consent to the operation. The contents include preoperative diagnosis, operation name, possible complications during or after operation, operation risk, patient's signature, doctor's signature, etc.

Twenty-fifth special examination, special treatment consent refers to the implementation of special examination, special treatment, the attending physician told the patient about the special examination, special treatment, and signed by the patient to agree to the examination and treatment of medical documents. The contents include special examination, the name and purpose of special treatment items, possible complications and risks, patient's signature, doctor's signature, etc.

Twenty-sixth discharge record refers to the attending physician's summary of the diagnosis and treatment of patients during hospitalization, which should be completed within 24 hours after discharge. The contents mainly include admission date, discharge date, admission situation, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge situation, discharge orders, doctor's signature, etc.

Twenty-seventh death records refer to the records of diagnosis, treatment and rescue of patients who died during hospitalization, which should be completed within 24 hours after the death of the patient. The contents include admission date, death time, admission situation, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of illness and rescue process), cause of death, death diagnosis and so on. Record the time of death to the minute.

Twenty-eighth death case discussion records refer to the death case discussion and analysis records presided over by the director of the department or a doctor with professional and technical qualifications above the deputy chief physician within one week of the patient's death. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.

Twenty-ninth doctor's advice refers to the doctor's advice issued in medical activities. The contents and starting and ending time of medical orders shall be written by doctors.

The contents of doctor's orders should be accurate and clear, each doctor's order contains only one item, and the time of release should be indicated, specific to minutes.

The doctor's advice cannot be changed. If cancellation is required, the word "cancellation" should be marked in red ink and signed.

Under normal circumstances, doctors may not give oral orders. When oral medical advice is needed to rescue critically ill patients, nurses should repeat it. After the rescue, the doctor should fill the doctor's advice truthfully immediately.

Medical orders are divided into long-term medical orders and temporary medical orders. The contents of the long-term medical order list include the patient's name, department, inpatient medical record number (or medical record number), page number, start date and time, long-term medical order content, stop date and time, doctor's signature, execution time and execution nurse's signature. The contents of temporary medical orders include the time of medical orders, the contents of temporary medical orders, the doctor's signature, the execution time and the execution nurse's signature.

Thirtieth auxiliary examination report refers to the records of various examinations and examination results made by patients during their hospitalization. The contents include the patient's name, gender, age, inpatient medical record number (or medical record number), examination items, examination results, report date, signature or seal of the reporter, etc.

Article 31 The temperature list is in the form of a form, which is mainly filled out by nurses. The contents include the patient's name, department, bed number, admission date, hospitalization medical record number (or medical record number), date, postoperative days, body temperature, pulse, respiration, blood pressure, stool frequency, fluid volume, weight, hospitalization weeks, etc.

Article 32 Nursing records are divided into ordinary patient nursing records and critically ill patient nursing records.

The nursing record of general patients refers to the objective record of the nursing process of general patients during hospitalization according to the doctor's advice and illness. The contents include patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, observation of illness, nursing measures and effects, and nurse's signature. Nursing record of critically ill patients refers to the objective record of nursing process of critically ill patients during hospitalization by nurses according to doctor's advice and illness. Nursing records of critically ill patients should be written according to the nursing characteristics of corresponding specialties. The contents include the patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other observations, nursing measures and effects, and nurse's signature. The recording time should be accurate to the minute.

Chapter IV Others

Article 33 The first page of hospital medical records shall be written in accordance with the Notice of the Ministry of Health on Amending and Printing the First Page of Hospital Medical Records (Wei [2001] No.286).

Article 34 The meaning of special examination and special treatment shall be in accordance with Article 88 of the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions issued by the Ministry of Health No.35 1994.

Article 35 The basic norms for writing medical records of traditional Chinese medicine shall be formulated separately.

Article 36 These Standards shall come into force as of September 6, 2002.