Internship Physician Handbook

Author: Lu Fengxiang
Publisher:
Publish Date: 2003-09-01
Features: In recent years, medical education and clinical medicine have achieved remarkable accomplishments. Advanced diagnostic and treatment technologies continue to develop, and new clinical drugs emerge constantly. The establishment and development of evidence-based medicine have laid a solid foundation for standardized diagnosis and treatment of diseases. Recent revisions have been made to the diagnosis and treatment of common conditions such as "hypertension," "heart failure," and "diabetes." Therefore, it is necessary to modify and expand this manual to enhance its scientific rigor, modernity, and applicability.
Writing concisely and directly is one of the key skills that intern physicians must master. According to the requirements of the Ministry of Health for medical record writing, the format of hospital admission records is divided into three types: admission records, repeated or multiple admission records, and 24-hour admission and discharge (death) records. No specific requirements are provided for hospital medical records ("big medical records").
The editors believe that intern physicians and first-year clinical trainees, in accordance with the requirements of "Diagnostics," should write complete and standardized hospital medical records as an indispensable part of strengthening "three foundations" training and laying a solid clinical foundation. The revision of this manual has not made significant changes to hospital medical records but has proposed more specific requirements for admission records, 24-hour admission and discharge (death) records, progress notes, and other aspects, in line with the relevant regulations and standards of the Ministry of Health for medical record writing.