What are some common mistakes medical students make when writing medical records for the first time?

When I was an intern, the teacher gave an example, in the past, the medical records were written by hand, and an intern wrote, "Today, Director XX made rounds of the ward, and after learning more about the patient's ** situation, he comforted the family, and when he left the ward to wash his hands, he shook his head and said no, alas, no." Then we were taught to write our medical records truthfully, but not in this way.

It started by copying and pasting, and then revising it, adding something the director said or did. Later, all the patients were handwritten about the patient, what they had done, and what they should pay attention to. Now I write about the patient's current situation, and what situation occurs or may have a situation, and then how to prevent it and how to deal with it, but I always like to add a sentence to pay attention to observation, observe at any time and other meaningless but indispensable.

Keep learning and keep improving.

After checking the room, I still won't analyze the condition when I come back, in fact, I just need to summarize the teacher's words. The test sheet will only be simply pasted and copied, and will not be screened and analyzed in combination with clinical practice. The physical examination has not changed from admission to discharge, etc., etc., etc., basically have to be rewritten, so if I am not sure that I will be with me for more than a month, I really don't want to write their medical records, it takes longer than writing them myself, and it is time to leave the department after teaching.

In addition, undergraduates basically don't do much clinical internship, and they basically can't see anyone for a few days, and they are ready to go to graduate school. Therefore, the undergraduate internship is basically a decoration now, and it is a pit for graduate students to make up for the undergraduate internship.

When I was an intern, the medical record of an intern doctor was taken out by the teacher as a key point, and his medical record was written like this: "The patient complained, trismus......”

I don't know how to write about colds and colds.

That is, the past is not complete! TCM Cases Diagnosis and symptoms are sometimes confused. Qi stagnation and blood stasis!!

Legal Analysis: The responsibility of a doctor for writing a wrong medical record is generally a warning from the health administrative department or an order to suspend the practice for a minimum of six months and a maximum of one year. However, it is usually only necessary to ask the doctor to make corrections.

If the doctor refuses to make corrections, the patient can go to the health administrative department to complain, and the doctor will have certain legal responsibilities. In addition, if the doctor suffers damage to the patient due to the fault of the doctor, he shall bear civil liability for compensation.

Legal basis: Article 1218 of the Civil Code of the People's Republic of China: Where a patient suffers damage in the course of diagnosis and treatment, and the medical institution or its medical staff is at fault, the medical institution shall bear the liability for compensation.

Summary. In the medical record, it is necessary to write a supplementary diagnosis or a revised diagnosis.

Is it necessary to write a supplementary diagnosis or a revised diagnosis in the writing of medical records? There is no mention of this in the spec.

In the medical record, it is necessary to write a supplementary diagnosis or a revised diagnosis.

Basic Standards for the Writing of Medical Records of Traditional Chinese Medicine and Integrated Traditional Chinese and Western Medicine (Trial) Chapter 1 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 course of medical reciting and congratulatory activities, including outpatient (emergency) medical records and inpatient medical records. Article 2: The writing of medical records refers to the examination of medical personnel through consultations, physical examinations, and auxiliary services

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 conduct inductive analysis and organize the formation of medical activity records.

The basic principles of medical record writing: medical record writing should be objective, truthful, accurate, timely and complete.

Time limit for writing medical records: inpatient medical records should be completed within 24 hours; The record of death within 24 hours of admission shall be completed within 24 hours of the patient's death; Where medical records are not written in a timely manner due to the rescue of critically ill patients, the relevant medical personnel shall record the facts within 6 hours of the end of the rescue and make a note of it.

The requirements for medical record writing are:

1. It should be objective, true, accurate, timely and complete, 2. Blue and black ink and carbon ink should be used when writing, 3. The text should be neat, the handwriting is clear and the expression is accurate, 4. It should be signed by the corresponding medical personnel.

On the one hand, it can protect the rights and interests of patients, improve the quality of medical records, ensure the quality and safety of medical treatment, and on the other hand, it can prevent misunderstandings and disputes between doctors and patients.

a) Objectivity. The patient's condition is actual and does not change by human will. Write medical records objectively according to the patient's description and actual examination results, without subjective speculation.

2) Authenticity. Medical personnel obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, nursing and so on, and summarize, analyze and sort out medical records, which can truly reflect the occurrence, development and return of patients' diseases.

3) Accuracy. The medical register staff strives to be accurate in their writing and wording, accurately describing and analyzing the patient's condition, and accurately diagnosing the disease.

The basic requirements for writing medical records are objectivity, truthfulness, accuracy, timeliness and completeness. On February 4, 2010, the Ministry of Health of the People's Republic of China issued a notice requiring that from March 1, 2010, the revised and improved "Basic Standards for Writing Medical Records" be implemented in all medical institutions across the country, which clearly stipulates that the basic requirements for writing medical records are objective, truthful, accurate, timely and complete.

Regarding medical records, the misdescription is that printed medical records are not a form of record for medical records.