Medical institution medical record writing specifications

Author: Peng Zhaoli
Publisher:
Publish Date: 2003-07-01
Features: This book is developed based on a thorough understanding of the spirit of the newly implemented Medical Accident Handling Regulations and the Basic Standards for Medical Record Writing (Trial Implementation) issued by the Ministry of Health, combined with the current medical service landscape. It was commissioned by the Health Department of Hubei Province and organized by the Medical Record Quality Monitoring Committee of the Hubei Provincial Hospital Management Society, with contributions from clinical experts and medical record management professionals. The content primarily includes the basic content and format of outpatient (emergency) medical records, the basic standards for inpatient medical records, the basic standards for medical records of various clinical specialties, the basic content of informed consent forms, and medical documents related to medical activities, followed by relevant laws, regulations, and rules. The basic standards for outpatient (emergency) medical records and inpatient medical records in this book have been officially adopted as standardized medical record formats by medical institutions across Hubei Province. The content is scientific, standardized, and legally compliant. The basic standards for specialty medical records serve as a reference for medical institutions to develop their own specialty inpatient records. The basic content of informed consent forms is provided for doctors to refer to during patient consultations. The basic content of informed consent forms covers numerous clinical specialties, making it practical, comprehensive, and directly applicable during conversations. This book can serve as a standardized reference for medical staff at all levels in medical institutions to write medical records; it is also particularly suitable for hospital management personnel to use as a reference.