The writing content of the basic norms of medical record writing in traditional Chinese medicine and integrated traditional Chinese and western medicine

Twelfth outpatient (emergency) medical records include outpatient medical records (outpatient manual cover), inpatient medical records, laboratory reports (inspection reports), medical imaging examination data.

Thirteenth outpatient (emergency) medical records should include the patient's name, gender, date of birth, nationality, marital status, occupation, work unit, address, drug allergy history and other items.

The cover content of outpatient manual should include the patient's name, gender, age, work unit or address, drug allergy history and other items.

Fourteenth outpatient (emergency) medical records are divided into initial medical records and follow-up medical records.

The contents of the first medical record should include the time of seeing a doctor, the patient, chief complaint, current medical history, past history, positive signs, necessary negative signs and auxiliary examination results, diagnosis and treatment opinions and doctor's signature, etc.

The contents of the follow-up medical record should include the time of visit, the patient, chief complaint, medical history, necessary physical examination and auxiliary examination results, diagnosis, treatment and treatment opinions, and doctor's signature.

The writing time of emergency medical records should be specific to minutes.

Fifteenth outpatient (emergency) medical records should be filled in by the attending physician in time during the patient's hospitalization.

Sixteenth when rescuing critically ill patients, rescue records should be written. For patients admitted to the emergency observation room, the observation records of the observation period shall be written.