The key points of medical record writing, the basic requirements for medical record writing are 6

The basic requirements for medical record writing are: objective, true, accurate, timely, complete and standardized.

1. Objectivity

It is all the phenomena of the patient's disease that really exists and does not depend on human will, and it is the content of the patient's reaction.

2. Authenticity

It is the embodiment of the results of the analysis of the patient's stated medical history and meaningful signs after the physician asks for the medical history, examines the patient, and examines the patient.

3. Accurate

It is to ask the physician to find out the content related to the disease from the large number of statements about the disease provided by the patient, and to process and refine it.

4. Timely

It is the medical staff who complete the writing of the corresponding medical record content within the specified time.

5. Complete

The physician should ask for a detailed and thorough medical history and physical examination, and all information in the medical record should not be lost.

6. Specification

It is to write the sickness and drought records in accordance with the provisions and requirements of laws and regulations, departmental rules, industry standards, etc.

The importance of medical record writing

A medical record is a comprehensive record of medical work and an important piece of legal evidence. At present, the relationship between doctors and patients is tense, and doctor-patient disputes often occur, the more important the role of medical records is, and it is necessary to pay attention to the writing of medical records.

Writing medical records is a very important task in clinical practice. Writing a complete and standardized medical record is the basic method for cultivating the thinking ability of clinicians and an important way to improve the professional level of clinicians. The quality of medical record writing is one of the objective test criteria for assessing the actual work ability of clinicians.

The requirements for medical record writing are that the medical record should be objective, true, accurate, timely, complete and standardized. Blue and black ink and carbon ink are used for medical record writing, and blue or black oil-water ballpoint pens can be used for medical record data to be copied. Computer-printed medical records shall meet the requirements for medical record preservation.

Legal basis] Article 3 of the Basic Standards for Writing Medical Records.

The writing of medical records shall be objective, truthful, accurate, timely and complete.

Article 4. Inpatient medical records should be written with blue-black ink and carbon ink, and blue-black or black oil-water ballpoint pens can be used for outpatient (emergency) medical records and materials that need to be copied.

Article 16 of the Regulations on the Handling of Medical Accidents.

In the event of a medical malpractice dispute, the records of the discussion of the death case, the discussion record of the difficult case, the record of the ward rounds of the senior physician, the consultation opinion, and the record of the course of the illness shall be sealed and unsealed in the presence of both the doctor and the patient. The sealed medical records can be photocopies and are kept by the medical institution.

1. Requirements for writing medical records.

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

Medical record writing refers to the behavior of medical personnel to obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, **, nursing, etc., and to induct, analyze, and organize the formation of medical activity records. The type of medical record.

1) According to the type: it is divided into outpatient medical records, outpatient manuals, emergency medical records, emergency observation medical records and inpatient medical records.

The basic concept of medical record writing is timely, objective and standardized.

The content is complete, the handwriting is clear, and it should not be altered at will.

1.General items.

Same as Western medicine inpatient medical records, plus onset solar terms.

2.Complaints. Describe the patient's perceived main pain (symptoms) and the time of onset.

3.History of present illness.

The time, season, place, cause, and evolution of the disease, the nature and extent of the main symptoms and related complications, the process of rash treatment and the effect response are described in detail.

4.Anamnesis.

Briefly describe the major diseases that you have suffered from in the past, the time and the circumstances, and reflect some information related to the disease.

5.Other histories.

Including personal history, family history. If it is a woman, it is necessary to record the history of menstruation and childbirth, and the history of feeding and growth of children should be recorded.

6.Fourth-day examination.

Distinguish priorities, highlight key points, and describe the objective information obtained by the four clinics. The main contents are as follows:

1) Visit: appearance, posture, tongue (texture, moss, moistness, shape), other abnormal phenomena (such as mouth, ears, nose, eyes, claws, macules, white, etc.), the color, nature and quantity of relevant secretions and excretions, pediatric fingerprints, etc.

2) Smell: sound (voice, breath and related abnormalities, such as cough, phlegm, vomiting, etc.), smell (including the smell of secretions and excretions).

3) Consultation: The main symptoms are now and other comorbidities.

4) Palpation: pulse incision (three parts and nine candidates), according to the abdomen and related head and neck, chest, limbs, spine, joints, etc. Old mill.

7.Dialectical analysis.

1) Identify **, pathogenesis, and disease location.

2) Analyze and determine the disease names and syndrome types of TCM, and put forward the basis for the identification of similar syndromes.

3) Estimate the progression and prognosis of the disease.

8.Summary of the physical examination.

T, P, R, BP, positive signs and related negative signs.

9.Physical and chemical examination.

List the findings and timing of tests that are meaningful for diagnosis and differential diagnosis.

10.Initial diagnosis.

Written at the bottom right. Chinese first and then Western, dual diagnosis (there is no exception to the corresponding Western medical diagnosis). TCM:

The name of the disease, the type and stage of the syndrome, and the patient may be careful to fill in more than one diagnosis [e.g., tuberculosis (yin deficiency type); Carbuncle (ulcerative phase)].Western Medicine:

Fill in the order of major diseases and concomitant diseases [e.g.: tuberculosis; lung abscess].

11.Signature.

Must be responsible for the review at the next level, and sign the full name at the bottom right.