In-patient medical records conform to the basic norms of Chinese medicine and integrated traditional Chinese and western medicine medical records writing.
Eighteenth hospital medical records refer to the records obtained by the attending doctor through consultation, physical examination and auxiliary examination after the patient is admitted to the hospital, and these materials are summarized, analyzed and written. The writing forms of hospitalization records are divided into admission records, readmission records, admission and discharge records within 24 hours, admission and death records within 24 hours.
Admission records and readmission records should be completed within 24 hours after the patient is admitted to the hospital; Admission and discharge records within 24 hours should be completed within 24 hours after the patient is discharged, and admission and death records within 24 hours should be completed within 24 hours after the patient dies.
Article 19 Requirements and contents of admission records:
(1) The general information of the patient includes name, gender, age, nationality, marital status, birthplace, occupation, date of admission, recording date, onset solar terms and medical history statement.
(2) Chief complaint refers to the main symptoms (or signs) of patients and the duration of treatment.
(3) The present medical history refers to the details of the occurrence, evolution, diagnosis and treatment of the patient's disease, which should be written in chronological order and recorded in combination with the requirements of TCM consultation. The contents include the incidence, the characteristics and development of main symptoms, accompanying symptoms, the course of disease and the results of diagnosis and treatment after onset, changes in general conditions such as sleep and diet, and positive or negative data related to differential diagnosis.
Other diseases that are not closely related to this disease but still need treatment can be recorded in another paragraph after the current medical history.
(4) Past history refers to the patient's past health and illness. The contents include general health status, disease history, infectious disease history, vaccination history, surgical trauma history, blood transfusion history, drug allergy history, etc.
(5) Personal history, marriage and childbearing history, menstrual history of female patients and family history.
(6) Physical examination writing should be systematic and orderly. The contents include body temperature, pulse, respiration, blood pressure and general conditions (including sight, shape, sound, qi, tongue picture, pulse, etc.). ), whole body skin, mucous membrane, superficial lymph nodes, head and its organs, neck, chest (chest, lungs, heart, blood vessels), abdomen (liver, spleen, etc. ), rectum and anus, and the outside.
(seven) the special circumstances of the profession should be recorded according to the needs of the profession.
(eight) auxiliary examination refers to the main examination and its results related to this disease before admission. The date of inspection shall be stated, and the name of the institution shall be stated if the inspection is carried out in other medical institutions.
(9) Preliminary diagnosis refers to the diagnosis made by the attending physician according to the comprehensive analysis of the patient when he is admitted to the hospital. If the initial diagnosis is multiple, the priority should be clear.
(ten) the signature of the doctor who wrote the admission record.
Twentieth readmission or multiple admission records refer to the records written by patients because of the same disease or staying in the same medical institution for many times. The requirements and contents are basically the same as the admission record, and its characteristics are as follows: the chief complaint records the main symptoms (or signs) and duration of the patient's admission; In the current medical history, it is required to summarize the previous hospitalization experience before this hospitalization, and then write the current medical history of this hospitalization.
Twenty-first patients who are discharged less than 24 hours after admission can write admission and discharge records within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, discharge time, chief complaint, admission, admission diagnosis, diagnosis and treatment process, discharge, discharge diagnosis, discharge doctor's order, doctor's signature, etc.
Twenty-second patients died less than 24 hours after admission, you can write a death record within 24 hours. The contents include the patient's name, gender, age, occupation, admission time, death time, chief complaint, admission situation, admission diagnosis, diagnosis and treatment process (rescue process), cause of death, death diagnosis, doctor's signature, etc.
Twenty-third course record refers to the continuous record of the patient's condition and diagnosis and treatment process after hospitalization record. The contents include the changes of the patient's condition and syndrome, the results of important auxiliary examinations and their clinical significance, superior doctors' rounds, consultation opinions, doctors' analysis and discussion opinions, diagnosis and treatment measures and effects, changes and reasons of doctor's orders, and important matters that need to be informed to patients and their close relatives.
Article 24 Requirements and contents of course records:
(a) the first course record refers to the first course record written by the attending physician or the doctor on duty after the patient is admitted to the hospital, which should be completed within 8 hours after the patient is admitted to the hospital. The contents of the first visit record include case characteristics, diagnosis basis, differential diagnosis and treatment plan. The basis of diagnosis includes the basis of disease differentiation in traditional Chinese medicine and the basis of diagnosis in western medicine, and the differential diagnosis includes the differential diagnosis of Chinese and western medicine.
(two) the daily course record refers to the regular and continuous record of the diagnosis and treatment process of patients during hospitalization. Written by doctors, but also by interns or trainee medical staff. When writing the daily course record, mark the date of the record first, and record the specific content in another line. For critically ill patients, the course of the disease should be recorded at any time according to the change of the condition, at least/kloc-0 times a day, and the recording time should be specific to minutes. For critically ill patients, the course of disease should be recorded at least once every 2 days. For patients with stable condition, the course of disease should be recorded at least once every 3 days. For patients with chronic diseases whose condition is stable, the course of disease should be recorded at least once every 5 days.
(3) The superior doctor's rounds record refers to the record of the patient's condition, syndrome, diagnosis, differential diagnosis, the analysis of the curative effect of the current treatment measures and the opinions on the next diagnosis and treatment.
The attending physician's first round of rounds should be completed within 48 hours after the patient is admitted to the hospital. The contents include name, professional and technical position, supplementary medical history and signs, diagnosis basis, differential diagnosis and treatment plan, etc. The time interval of the attending physician's daily rounds is determined according to the condition and diagnosis and treatment, including the name of the attending physician, professional and technical positions, condition analysis and diagnosis and treatment opinions. The records of ward rounds of doctors with professional and technical positions or above, including the names of ward rounds doctors, professional and technical positions, illness analysis, diagnosis and treatment opinions, etc.
(4) The discussion record of difficult cases refers to the record presided over by the director of the department or a physician with professional and technical qualifications above the deputy chief physician, and convened relevant medical personnel to discuss cases with difficult diagnosis or uncertain curative effect. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.
(5) The shift (pick-up) record refers to the record that the shift doctor and the succession doctor briefly summarize the patient's condition and diagnosis and treatment respectively when the patient's attending doctor changes. The log record shall be filled in by the log doctor before the log; The shift record shall be completed by the shift doctor within 24 hours after the shift. The contents of the handover record include admission date, handover or handover, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in handover or handover diagnosis and treatment scheme, and doctor's signature, etc.
(6) The record of changing majors refers to the records written by the doctors in the transfer-out department and the transfer-in department respectively after the patient needs to change majors during hospitalization and agrees to receive them. Include a transfer-out record and a transfer-in record. The transfer-out record is written by the doctor in the transfer-out department before the patient is transferred out of the department (except for emergency); The transfer-in record should be completed by the doctor in the transfer-in department within 24 hours after the patient is transferred. The contents of transfer record include admission date, transfer-out or transfer-in date, patient's name, gender, age, chief complaint, admission status, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, matters needing attention in transfer-out or transfer-in treatment scheme, and doctor's signature.
(7) Stage summary refers to the summary of the patient's condition and diagnosis and treatment by the attending doctor every month after long-term hospitalization. The contents of the stage summary include admission date, summary date, patient's name, gender, age, chief complaint, admission, admission diagnosis, diagnosis and treatment process, current situation, current diagnosis, diagnosis and treatment plan, doctor's signature, etc.
Changes in handover (pick-up) records and main records can replace stage summary.
(eight) the rescue record refers to the record made when the patient is in critical condition and takes rescue measures. The contents include the change of illness, the time and measures of rescue, the names of medical personnel who participated in the rescue and their professional and technical positions. Record the rescue time to the minute.
(nine) consultation records (including consultation opinions) refers to the records written by the applicant and the consultant respectively when the patient needs the assistance of other departments or other medical institutions during hospitalization. The contents include application for consultation records and consultation opinions records. The record of application for consultation shall briefly explain the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and shall be signed by the consultant. The consultation opinion record should include the consultation opinion, the name of the department or medical institution where the consultant works, the consultation time and the signature of the consultant.
(10) Preoperative summary refers to the summary of the patient's condition made by the attending physician before operation. The contents include brief illness, preoperative diagnosis, surgical indications, the name and method of the operation to be performed, the anesthesia method to be performed, and matters needing attention.
(1 1) Preoperative discussion record refers to the record of discussing the proposed operation method, possible problems during operation and countermeasures under the auspices of the superior doctor before operation because of the patient's serious illness or difficulty in operation. The contents include preoperative preparation, surgical indications, surgical plan, possible accidents and preventive measures, names of participants, professional and technical positions, discussion date, signature of recorder, etc.
(12) Anesthesia record refers to the record of anesthesia process and treatment measures written by anesthesiologists during anesthesia implementation. Anesthesia records should be written on a separate page, including the general situation of patients, medication before anesthesia, preoperative diagnosis, intraoperative diagnosis, anesthesia mode, medication and treatment during anesthesia, starting and ending time of operation, signature of anesthesiologist, etc.
(thirteen) the operation record refers to the special record written by the operator to reflect the general situation of the operation, the operation process, the findings and handling during the operation, and shall be completed within 24 hours after the operation. Under special circumstances, when written by the first assistant, it should be signed by the operator. The operation record should be written on a separate page, including general items (patient's name, gender, department, ward, bed number, inpatient medical record number or medical record number), operation date, preoperative diagnosis, intraoperative diagnosis, operation name, operator's and assistant's name, anesthesia method, operation process, intraoperative situation and treatment, etc.
(14) surgical nursing records refer to the records made by visiting nurses on the nursing situation of surgical patients and the instruments and dressings used, which should be completed immediately after the operation. Surgical nursing records should be written on a separate page, including the patient's name, hospital medical record number (or medical record number), operation date, operation name, intraoperative nursing situation, counting and checking the number of various instruments and dressings used, and the signatures of visiting nurses and surgical instrument nurses.
(15) The first course record after operation refers to the course record completed by the doctors involved in the operation immediately after the operation. The contents include operation time, intraoperative diagnosis, anesthesia mode, operation mode, brief operation flow, postoperative treatment measures and matters needing special attention after operation.
Twenty-fifth operation consent refers to the medical document that the patient is informed by the attending physician before the operation and the patient signs the consent to the operation. The contents include preoperative diagnosis, operation name, possible complications during or after operation, operation risk, patient's signature, doctor's signature, etc.
Twenty-sixth special examination and special treatment consent refers to the medical documents before the implementation of special examination and special treatment, which are informed by the attending physician to the patients and signed by the patients to agree to the examination and treatment. The contents include special examination, the name and purpose of special treatment items, possible complications and risks, patient's signature, doctor's signature, etc.
Twenty-seventh discharge record refers to the attending physician's summary of the diagnosis and treatment of patients during hospitalization, which should be completed within 24 hours after discharge. The contents mainly include admission date, discharge date, admission situation, admission diagnosis, diagnosis and treatment process, discharge diagnosis, discharge situation, discharge orders, doctor's signature, etc.
Twenty-eighth death records refer to the records of diagnosis, treatment and rescue of patients who died during hospitalization, which should be completed within 24 hours after the death of patients. The contents include admission date, death time, admission situation, admission diagnosis, diagnosis and treatment process (focusing on recording the evolution of illness and rescue process), cause of death, death diagnosis and so on. Record the time of death to the minute.
Twenty-ninth death case discussion records refer to the death case discussion and analysis records presided over by the director of the department or a doctor with professional and technical qualifications above the deputy chief physician within one week of the patient's death. The contents include the date of discussion, the names of the host and participants, professional and technical positions, discussion opinions, etc.
Thirtieth doctor's advice refers to the doctor's advice issued in medical activities.
The contents and starting and ending time of medical orders shall be written by doctors.
The contents of doctor's orders should be accurate and clear, and each doctor's order contains only one content, and the release time should be indicated, specifically to minutes.
The doctor's advice cannot be changed. When cancellation is required, the word "cancellation" should be marked with red ink and signed.
Under normal circumstances, doctors may not give oral orders. When oral medical advice is needed to rescue critically ill patients, nurses should repeat it. After the rescue, the doctor should fill the doctor's advice truthfully immediately.
Medical orders are divided into long-term medical orders and temporary medical orders.
The contents of the long-term medical order list include the patient's name, department, inpatient medical record number (or medical record number), page number, start date and time, long-term medical order content, stop date and time, doctor's signature, execution time and execution nurse's signature. The contents of temporary medical orders include the time of medical orders, the contents of temporary medical orders, the doctor's signature, the execution time and the execution nurse's signature.
Thirty-first auxiliary examination report refers to the records of various examinations and examination results made by patients during their hospitalization. The contents include the patient's name, gender, age, inpatient medical record number (or medical record number), examination items, examination results, report date, signature or seal of the reporter, etc.
Article 32 The temperature list is in the form of a form, which is mainly filled out by nurses. The contents include the patient's name, department, bed number, admission date, hospitalization medical record number (or medical record number), date, postoperative days, temperature, pulse, respiration, blood pressure, stool frequency, fluid volume, weight and hospitalization weeks.
Article 33 Nursing records are divided into ordinary patient nursing records and critically ill patient nursing records.
The nursing record of general patients refers to the objective record of the nursing process of general patients during hospitalization according to the doctor's advice and illness. The contents include patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, observation of illness, nursing measures and effects, and nurse's signature.
Nursing record of critically ill patients refers to the objective record of nursing process of critically ill patients during hospitalization by nurses according to doctor's advice and illness. Nursing records of critically ill patients should be written according to the nursing characteristics of corresponding specialties. The contents include the patient's name, department, inpatient medical record number (or medical record number), bed number, page number, recording date and time, fluid volume, body temperature, pulse, respiration, blood pressure and other observations, nursing measures and effects, and nurse's signature. The recording time should be accurate to the minute.
Nursing measures of traditional Chinese medicine should reflect dialectical nursing.