Medical record writing basic specifications practical manual

Author: Wu Dianyuan
Publisher:
Publish Date: 2004-04-01
Features: The book consists of 12 chapters and approximately 300,000 words. Chapter Overview introduces the definition, classification, functions, and basic requirements for writing medical records, as well as the interpretation of common terms; Chapter 2: Outpatient (Emergency) Medical Record Writing Requirements and Examples, comprehensively covers the writing requirements and examples for outpatient (emergency) medical records; Chapter 3: Inpatient Medical Record Writing Requirements and Examples, provides detailed introductions to the writing requirements and examples for the medical record home page, admission records, various inpatient histories, and tabular medical records; Chapter 4: Specialty Admission Record Writing Requirements and Examples, introduces the writing requirements and examples for nearly 30 specialty admission records in practical contexts; Chapters 5 and 6: T (Course of Illness Records) and Other Records Writing Requirements and Examples, systematically introduce the writing requirements and examples for various course of illness records and other records; Chapter 7: Informed Consent Form, introduces the content, format, and examples of the informed consent form; Chapter 8: Medical Orders, introduces the writing requirements for medical orders; Chapter 9: Nursing Documentation, introduces the content, requirements, and common nursing documentation forms; Chapter 10: Auxiliary Examination Request Forms and Reports, introduces the basic writing requirements for auxiliary examination request forms and reports, as well as examples of over 20 request forms and reports; Chapters 11 and 12 are dedicated to medical record management, covering not only conventional content but also new requirements for related matters. At the end of the book, there are 4 appendices. The content of this book is systematic, comprehensive, accurate, and practical, making it suitable for use in hospitals of all levels. It serves as a practical reference for hospital administrators, clinical medical and technical professionals, resident physicians, and intern physicians. The book consists of 12 chapters and approximately 300,000 words. Chapter Overview introduces the definition, classification, functions, and basic requirements for writing medical records, as well as the interpretation of common terms; Chapter 2: Outpatient Medical Record Writing Requirements and Examples; Chapter 3: Inpatient Medical Record Writing Requirements and Examples; Chapter 4: Specialty Admission Record Writing Requirements and Examples, etc.