Medical records, also known as the case record, medical record, medical records, medical history, medical records, refers to the medical workers in the clinical work of Chinese medicine in patients with the disease, used to record the evolution of prognosis, diagnosis and treatment, and the results of the original file protection measures. Chinese history has a long history, is an important part of Chinese classical medical books. The Chinese nation has attached great importance to and spread of medical records, in the multitude of ancient books of traditional Chinese medicine, the preservation of a large number of ancient medical records and medical records album. Account for the disease of the Shang Dynasty Oracle, is the earliest medical records. The Western Han Dynasty, Sima Qian in "records of the historian Bian Que Cang Gong biography" wrote "his meaning the diagnosis, all has the case record". The so-called "case record" is "record ''. Recorded in the book of the Western Han Dynasty famous doctor Yi's case record of 25, is the oldest Chinese medical records. Jin · Ge Hong "zhouhoubeijifang", "Sui Dynasty, Chao Yuanfang based" may be found in some scattered in the medical record. After the Tang and Song Dynasties, medical records began to prevail, song, written by Xu Shuwei "typhoid ninety theory" is the first diseaseThe monograph. During the Ming and Qing Dynasties, the collection and study of medical work seriously, a lot of medical classics still is that people learn, such as Ming Xue Ji Xue's medical records "," Qing, ye Tianshi "guide to clinical practice", many doctors put forward their own record format, there are a lot of medical classics still is that people learn such as Han Mao, Li Dan, Wu Kun, et al. Have put forward their own record format. Han Mao in the "Han Medicine through" "six and the chapter" in put forward a complete medical diagnosis. Han's thought should pack at medical forms, audible sound, shape, cut, on the principles of love, including 6 pathogenic cure most, and developed a more formal record format. In 1584, the Ming Dynasty physician Wu Bi further generalization of the record format in the "pulse" of language, provides 7 parts, one is the time origin name; two is inspection and olfaction, which combined pulse; three is the patient's disease, and time of onset, the mental state and disease duration; four is the beginning the incidence, treatment and curative effect; five is the day is very cold and heat, which, like what is evil, disease status, to distinguish the blood, yin and Yang, Zang Fu Cha; six is to write the name of disease diagnosis, and diagnosis according to the theory, distinguish the samples priorities, identify a reservoir when the patch, a reservoir when diarrhea; seven the prescription and drug addition and subtraction, write clear prescription, drug combination method. Wu also pointed out that the medical record shall be signed by responsible, medicine, the medicine in inspection work station. Added his "six facilities' 'and Wu, plays a foundation role important to record format standardization.
Since July 1, 2010, the Ministry of health, the State Administration of traditional Chinese medicine traditional Chinese medicine jointly issued the "basic norms of medical records" (Chinese medicine medicine g 29) (hereinafter referred to as the "new" standard "") formally implemented, the 2002 edition of "the writing of medical records of traditional Chinese medicine and Western medicine combined with traditional Chinese medicine, based on this specification (Trial)" abolished at the same time. The new "norms" of traditional Chinese medical records to improve the standardization, standardization construction, improve the medical quality. "Chinese medicine basic norms of medical records (First Edition)" the writing purpose, aims to implement the "traditional Chinese medical record writing standard", the relevant provisions of the Ministry of health and the State Administration of traditional Chinese medicine traditional Chinese medicine standard construction. "Chinese medicine basic norms of medical records (First Edition)" the basic principles are: "norms" prominent focus, focus on the "standard" connotation; ② focuses on characteristics and scientific, systematic, integrity, the law of TCM medical records should be strengthened; clinical Chinese medicine basic skills training, standardize medical records writing behavior; the embodiment and adapt to the new situation in the reform of the medical and health; excellent records and absorption of national model hospital of traditional Chinese medicine; the preparation of participation by the Ministry of health and the State Administration of traditional Chinese medicine "Chinese medicine basic norms of medical records" revision of the project group of experts. "Chinese medicine basic norms of medical records (First Edition)" the main contents include the traditional Chinese medical record writing principles; basic specification of traditional Chinese Medical Record Writing II (including writing contents and requirements, medical emergency outpatient records the contents and requirements of medical records, the contents and requirements of various kinds of medical records, record the contents and requirements for example, medical record writing essentials the main clinical departments, all kinds of informed consent form); TCM medical records checking evaluation standard; the appendix (including medical records management, medical electronic medical records the basic requirements).
Ministry of health, the State Administration of traditional Chinese medicine on the written notice issued "basic norms of medical records of traditional Chinese medicine of TCM medical records" basic norms of TCM medical records writing 1 modified 1.1 basic requirements for text, format and language required the 1.2 medical records personnel qualification requirements 1.3 medical record writing time 1.4 medical records of the 1.5 basic requirements of medical records 1.6 order 2 (emergency) examination records the contents and requirements of 2.1 clinic records of 2.2 outpatient visit record of 2.3 emergency patients records of 2.4 emergency records of 2.5 emergency course record 2.6 (emergency) diagnosis of EMR 3 hospital medical record writing content and requirement of 3.1 hospital admission records within 3.224 hours of admission and discharge records within 3.324 hours of hospitalization death records from 3.4 for the first time duration record 3.5 daily course record 3.6 superior records of ward round.3.7 difficult case discussion record 3.8 shift record 3.9 succession records. Recorded 3.11 to 3.10 out of 3.12 stage summary record 3.13 rescuing records of 3.14 invasive diagnosis and treatment records of 3.15 consultation records of 3.16 preoperative summary 3.17 preoperative discussion records of 3.18 preoperative anesthetic interview recording 3.19 anesthesia record 3.20 operation records of 3.21 operation safety inspection record 3.22 operation count records 3 After.23 for the first time duration record interview recording 3.25 discharge records 3.26 deaths recorded 3.27 deaths on record 3.28 was 3.24 after anesthesia (dying) nursing records and 3.29 orders 3.30 temperature 4 main clinical professional medical record writing characteristics of 4.1 cardiovascular professional 4.2 breathing professional 4.3 spleen and stomach disease professional 4.4 professional 4.5 professional 4.6 blood endocrine disease professional 4.7 neural professional 4.8 rheumatology professional 4.9 professional 4.10 professional 4.11 tumor surgery orthopedics professional 4.12 urinary professional 4.13 anorectal professional 4.14 professional skin 4.15 gynecological professional 4.16 pediatric professional 4.17 geriatric professional 4.18 professional 4.19 professional massage acupuncture 4.20 Department of Ophthalmology 4.21 professional ear nose throat professional 5 informed consent 5.1 our country about the patient's right of informed consent Law Article 5.2 "Chinese medicine basic norms of medical records" on the informed consent document requirements 5.3 general told the template 5.4 TCM clinical subjects informed consent form 5.5 branches of general consent template 6 Chinese medical record quality inspection evaluation standard 6.1 door (urgent) diagnosis calendar quality inspection 6.2 evaluation standard of medical record quality check-up 7 evaluation standard appendix 7.1 of the people's Republic of China practice Medical act 7.2 medical records management regulations 7.3 TCM basic norms of electronic medical records (for Trial Implementation) 7.4 State Administration of traditional Chinese medicine on notice to amend the issuance of TCM medical records of 7.5 Ministry of health basic norms of medical records management Ordinance of 7.6 medical institutions, 7.7 Medical Malpractice handling regulations of 7.8 of the people's Republic of China Tort Liability Act (Chapter seventh of the liability of medical damage) the detailed rules for the implementation of the measures for the administration of the 7.9 operation safety verification system 7.10 prescription 7.11 Medical Institutions Management Ordinance of 7.12 TCM syndrome classification and codes
[Specification] 1 admission records refer to patients after admission, by the treating physician to look, smell, ask, cut and physical examination, auxiliary examination to obtain relevant information, analyze and summarize the writing and recording the data. Can be divided into the hospital records, again or repeatedly hospital admission records, within 24 hours of admission and discharge records, 24 hours of admission death records. The hospital records, again or repeatedly hospitalized records shall be completed within 24 hours after 24 hours in patients; people hospital discharge records shall be completed within 24 hours after discharge from hospital, 24 hours of admission death records should be completed within 24 hours after death. Requirements and contents of the 2 admission records. 1) the general condition of the patient including name, gender, age, nationality, marital status, occupation, place of birth, the hospital time, recording the time, the incidence of solar term, the history makers. 2) complained of symptoms prompted refers to patients (or symptoms) and duration. 3) present disease refers to patients with conditions of the disease, diagnosis and treatment of evolution, etc., should be written according to the time sequence, and combining the current situation of interrogation, record. The contents include changes in incidence, characteristics and development changes of main symptoms, associated symptoms, onset after treatment and result, sleep and diet in general, and the differential diagnosis of positive or negative information. I. incidence: record onset time, location, onset, prodromal symptoms, possible causes or inducements. II. The main symptom characteristics and development changes: according to the sequence of the main symptoms of the site, describes the nature, duration, extent, alleviate or aggravating factors, as well as the development situation. Ⅲ. Symptom: recording accompanying symptoms, describe the relationship between symptoms and accompanied symptoms. Ⅳ. Since the onset process of diagnosis and treatment, results: the records of patients to the hospital before with after effect, and accept the examination and treatment in the hospital, outside the hospital. The drug name, diagnosis and operation name patients need quotes ("") to show the difference between. V. Since the onset usually combined with summary records: for patients after onset of chills and fever, diet, sleep, emotional, two, weight etc.. And without the disease closely related but still need other disease treatment, in the present history after another paragraph shall be recorded. 4) refers to the past history of patients in health and disease. Were the general health status, medical history, history of infectious diseases, vaccination history, operation trauma history, history of blood transfusion, food or drug allergy history. 5) personal history, obstetrical history, menstrual history, family history.
"Chinese medicine basic norms of medical records (First Edition)" outstanding "Chinese medical record writing standard" focus, focus on the connotation of. Standard medical records writing behavior, strengthen the basic skills of clinical Chinese medicine. The excellent record absorption National Model Hospital of traditional Chinese medicine. The Ministry of health and the State Administration of traditional Chinese medicine "Chinese medicine basic norms of medical records" revision project group of experts to write. Interpretation of the authority, matching requirements, application.
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