Medical record writing for common oral diseases, oral medical record writing specifications emergen

Article 11 The contents of outpatient (emergency) medical records include the first page of outpatient medical records (the cover of outpatient manuals), medical records, laboratory test sheets (test reports), medical imaging examination materials, etc.

Article 12 The content of the first page of the outpatient (emergency) medical record shall include the patient's name, gender, date of birth, ethnicity, marital status, occupation, work unit, address, drug allergy history and other items.

The written content of the initial medical record shall include the time of consultation, department, chief complaint, present medical history, past medical history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and ** opinion and physician's signature.

The written content of the medical record of the follow-up examination shall include the time of consultation, department, chief complaint, medical history, the results of the physical examination and auxiliary examinations necessary for the child, the diagnosis, the handling opinion, and the signature of the physician.

Article 14: Outpatient (emergency) medical records shall be completed by the attending physician in a timely manner at the time of the patient's visit.

Article 15: When rescuing critically ill patients, rescue records shall be written. For patients admitted to the observation room of the emergency room, an observation record should be written during the observation period.

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 activities, including outpatient (emergency) medical records and inpatient medical records.

Article 2: Medical record writing refers to the act of medical personnel obtaining relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, nursing, etc., and inducting, analyzing, and sorting out medical activity records.

Article 3: 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 or black oil-water ballpoint pens can be used for outpatient (emergency) medical records and materials that need to be copied.

Article 8 Knowing Liangliang Article Superior medical personnel have the responsibility to review and revise the medical records written by lower-level medical personnel. When revising, the date of the modification shall be indicated, the person making the modification shall sign it, and the original record shall be kept clear and legible.

Article 9: Where medical records are not written in a timely manner due to the rescue of critically ill patients, the relevant medical personnel shall make up the record within 6 hours of the end of the rescue and make a note of it.

Article 10 For medical activities that require the written consent of the patient in accordance with the relevant provisions (such as special examinations, special examinations, surgeries, experimental medical treatment, etc.), the patient shall sign a consent form. When the patient does not have full capacity for civil conduct, it shall be signed by his or her legal person; If the patient is unable to sign due to illness, it shall be signed by his close relatives, and if there are no close relatives, his or her related persons shall sign; In order to save patients, the person in charge of the medical institution or the authorized person in charge may sign in a timely manner if the legal person or a close relative or related person does not notice the dust law and sign in a timely manner.

Where it is not appropriate to explain the situation to the person suffering from Zen failure due to the implementation of protective medical measures, the patient's close relatives shall be notified of the relevant circumstances, and the patient's close relatives shall sign a consent form and record it in a timely manner. If the patient has no close relatives or the patient's close relatives are unable to sign the consent form, the patient's legal ** person or related person shall sign the consent form.

(1) The cover page of the outpatient medical record should be filled in carefully one by one. Patient's name, sex, age, place of work.

Or the address, clinic number, and public (self) fee shall be filled in by the ** room. X-ray number, electrocardiogram and other special examination numbers, drug allergies, hospitalization numbers and other items shall be filled in by the physician.

2) The medical record of the newly diagnosed patient should contain "five signatures" (chief complaint, medical history, physical examination, preliminary diagnosis, treatment opinions and physician's signature). Among them: The medical history should include the history of present illness, the history of existing symptoms, and the personal history related to the disease, marriage, menstruation, childbirth, family history, etc.

Physical examination should record major positive and differential negative signs. The names of preliminarily determined or most likely disease diagnoses are listed separately, and the words "to be investigated" and "to be diagnosed" should be avoided as much as possible. The treatment opinions should be listed in the branch of drugs and special methods, items for further examination, life precautions, rest methods and periods; If necessary, record the date of appointment and follow-up requirements.

3) Follow-up patients should focus on the results of diagnosis and treatment and the evolution of the disease after the previous visit; Physical examination may be emphasized, and the last positive finding should be repeated, and new signs should be noted; Supplemental ancillary examinations and special examinations as necessary. For patients who cannot be diagnosed three times, the attending physician should consult a senior physician. For diseases that are different from the previous time, the outpatient medical record will be written according to the first patient.

4) The date of visit should be filled in for each visit, and the emergency patient should fill in the specific time.

5) When requesting consultation with other departments, the purpose of the request, the requirements and the preliminary opinions of the department should be clearly filled in on the medical record, and signed by the senior physician of the hospital.

6) The invited consulting physician (senior physician of our hospital) should fill in the examination findings, diagnosis and treatment opinions on the medical record of the consultation.

7) When an outpatient needs to be inpatient for examination and **, the physician shall fill in the hospitalization certificate.

8) The outpatient physician shall be responsible for filling in the summary of the medical record for the referred patient.

9) The epidemic situation of notifiable infectious diseases should be indicated.

There are content dates, times, events, questions. Wait a minute!

Chief complaint: must have the location, symptoms, and timing.

History of present illness: history of the course of the complaint, oral hygiene habits, history of smoking and drinking, etc.

Anamnesis: Other oral history, no special circumstances are written.

Family history: If the patient has similar symptoms, then hereditary diseases such as adolescent gingivitis, pregnancy gingivitis, and tumors should be written about whether there are any, and others should be written to deny the special.

Diagnosis: Written on the right side, there may be multiple diagnoses, with the chief complaint taking precedence and the rest of the heavier ones taking precedence.

Design: Write out the order according to the diagnosis Write it down like this.

Disposition: Write in the order in which you did what you did to the patient.

Signature: Write on the right side Signature of the senior doctor Sign by yourself If you have a license, just write your own name.