Medical record writing legal documents of Ministry of health, the State Administration of traditional Chinese medicine on the issuance of "medical records management provisions of the" Notice of the Ministry of health, the State Administration of traditional Chinese medicine on the issuance of "basic norms of medical records (for Trial Implementation)" the notice of the Ministry of health, the national Chinese Medicine Administration issued "basic norms of medical records, traditional Chinese medicine and Western medicine combined with traditional Chinese medicine (for Trial Implementation)" the basic provisions of the notice notice of the Ministry of Health issued a revision of inpatient medical records in the first chapter of overview of etiology, classification standard of medical records and the definition of position and function of second writing two, medical records, the two section a format, time limit three, second chapter book writing requirements and specifications and types of records format and content first records of inpatient medical records of outpatient medical emergency (stay) hospital admission records complete medical record 24 hours of admission and discharge records again or repeatedly hospitalized records transferred chart format medical plan or plan table records clinical case discussion record consultation records transfer and receiving record log Operation summary of discussion before recording operation before operation anesthesia anesthesia classification standard discharge records death records within 24 hours of admission deaths on record in hospital medicine belongs to the death records (long-term, temporary) writing rules and requirements of disease in other records calendar section second medical standard of prescription writing section third all kinds of inspection, treatment application and report writing and fourth sections medical order chapter third hospitalized cases (case) medical quality evaluation standard of the fourth chapter of medical record management @##@ appendix Medical record is the sum of hospital medical staff in medical activities in various records, is the comprehensive reflection of the level of hospital medical quality and management. Medical records as a valuable information to the hospital, and provide the basis for clinical, teaching, research work and have the force of law. The hospitals at all levels must attach great importance to the cause of writing, to strengthen the medical record writing work standardization, standardization management. The book in addition to the original "record writing standard and regulations and cases (case) evaluation standard" quality of medical cases in the method of appraising medical defects and grading standards of the necessary modifications, also increased the medical records writing, some departments table records, doctor-patient communication, all kinds of inspection, treatment records the application and report writing, case management and appendix content, delete the medical quality score rules; in the evaluation standard and adding the content of hospital infection, delete the "other" content; emphasizes the diagnosis, treatment and operation treatment quality, further embodies the humanized service concept of scientific, practical, can the operation principle and human-oriented.
Medical Science @ 2017